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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:
354 2021-11-04 16:26 Anonymous (not verified) 97.64.194.58 D&D Construction 1124 West Donald ST, Waterloo IA 50703 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. 2021-11-04 Darrel Caldwell dcaldwell1124@yahoo.com Waterloo Black Hawk County IA Scott Joseph Demuth Catrese Caldwell Signed (1) The corporation rejects the employers’ liability coverage. NA dcaldwell1124@yahoo.com NA NA NA NA NA NA Signed
552 2022-10-03 11:50 Anonymous (not verified) 173.18.48.197 Rancheros construction LLC 1121 Linn 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. 2022-09-25 Salvador Alvarez rancherosconstruction@outlook.com Waterloo Black hwak Iowa Jose Sergio Signed (1) The corporation rejects the employers’ liability coverage. Salvador Alvarez rancherosconstruction@outlook.com N/a Waterloo Black hawk Iowa Jose Sergio Signed
58 2020-04-14 08:32 Anonymous (not verified) 174.217.17.57 Society of St Vincent de Paul, District Counsel Waterloo Iowa 320 Broadway St PO Box 2727 Waterloo IA 50704 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. 2020-04-14 Rodney Crowe crorod@aol.com Waterloo Blackhawk Iowa George W Karnivk Glynis R Worthington Signed (1) The corporation rejects the employers’ liability coverage. Joseph D Sobczyk joczyk@aol.com Corporate Treasurer Cdear Falls Blackhawk Iowa George W Karnick Glynis R Worthington Signed
533 2022-09-08 11:04 Anonymous (not verified) 174.198.66.66 WCDEVINE LLC dba Five Star Painting of Cedar Falls 6333 Leversee Road 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. 2022-09-08 Wade Devine (owner) Wade.Devine@fivestarpainting.com Waterloo Blackhawk Iowa Brad Johnson Tom Wildeboer Signed (1) The corporation rejects the employers’ liability coverage. Wade Devine Wade.Devine@fivestarpainting.com Owner/Same person Waterloo Blackhawk Iowa Brad Johnson Tom Wildeboer Signed
537 2022-09-20 09:01 Anonymous (not verified) 173.20.206.50 Accent Painting LLC 613 Locust 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. 2022-09-20 Anthony Gilbert Gasco accentpainting@yahoo.com La Porte City Blackhawk Iowa Arthur Rudolf Gasco Aurora Jealee Gasco Signed (1) The corporation rejects the employers’ liability coverage. Anthony Gilbert Gasco accentpainting@yahoo.com Owner La Porte City Blackhawk Iowa Arthur Rudolf Gasco Aurora Jealee Gasco Signed
967 2024-05-01 06:30 Anonymous (not verified) 94.188.207.224 Cael Gulrud 206 W Main St Calmar, IA, 52132 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-01 Brandon Gulrud mojopants21@gmail.com Waterloo Blackhawk IA Victoria Bacon-Ortiz David Gulrud Signed (1) The corporation rejects the employers’ liability coverage. Cael Gulrud gulrud8728@gmail.com Owner Calmar Winneshiek IA Victoria Bacon-Ortiz David Gulrud Signed
739 2023-08-11 18:02 Anonymous (not verified) 94.188.205.176 Frontline Roofing & Construction LLC 310 W Gilbert Dr I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2023-08-10 Verónica Santos FrontlineR-C@outlook.com Evansdale BlackHawk County IA Angela Hernandez Kevi Hernandez Signed (2) The corporation declines to reject the employers’ liability coverage. Veronica Santos angelasermeno@gmail.com Owner Evansdale BlackHawk IA Angela Hernandez Signed
32 2020-01-14 10:33 Anonymous (not verified) 108.171.132.189 B & C Lawn Care Inc P.O. Box 55, Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-01-01 Travis Garrett onethird4599@gmail.com Boone Boone Iowa Katie Frame Jessica Carroll Signed (1) The corporation rejects the employers’ liability coverage. Travis Garrett onethird4599@gmail.com Owner Boone Boone IOWA Katie Frame Jessica Carroll Signed
34 2020-01-16 13:10 Anonymous (not verified) 108.171.132.188 B & C Lawn Care Inc P.O. Box 55, Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-01-01 Caleb Elliott onethird4599@gmail.com Boone Boone Iowa Katie Frame Jessica Carroll Signed (1) The corporation rejects the employers’ liability coverage. Caleb Elliott onethird4599@gmail.com Owner Boone Boone IOWA Katie Frame Jessica Carroll Signed
402 2022-02-09 09:46 Anonymous (not verified) 69.57.33.202 Toby K's Hideaway Inc. dba Toby K's Hideaway 1723 Mamie Eisenhower Ave, Boone IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-09 Toby Kruse samanthapeck@boehmins.com Boone Boone Iowa Samantha Peck Hans Boehm Signed (1) The corporation rejects the employers’ liability coverage. Toby Kruse samanthapeck@boehmins.com Owner Boone Boone Iowa Samantha Peck Hans Boehm Signed
663 2023-05-03 12:53 Anonymous (not verified) 94.188.205.177 Seven Oaks Recreation 1086 222nd Dr., Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-03 Joel Bryan joel@sevenoaksrec.com Ogden Boone United States Anthony Calek Craig Christensen Signed (1) The corporation rejects the employers’ liability coverage. Sara Bryan sara@sevenoaksre.com Director/Vice-President/Secretary Boone Boone United States Anthony Calek Craig Christensen Signed
664 2023-05-03 12:54 Anonymous (not verified) 94.188.205.174 Seven Oaks Recreation 1086 222nd Dr., Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-03 Sara Bryan sara@sevenoaksrec.com Ogden Boone Iowa Anthony Calek Craig Christensen Signed (1) The corporation rejects the employers’ liability coverage. Sara Bryan sara@sevenoaksre.com Director/Vice-President/Secretary Boone Boone United States Anthony Calek Craig Christensen Signed
665 2023-05-03 12:54 Anonymous (not verified) 94.188.205.169 Seven Oaks Recreation 1086 222nd Dr., Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-03 Joel Bryan joel@sevenoaksrec.com Ogden Boone Iowa Anthony Calek Craig Christensen Signed (1) The corporation rejects the employers’ liability coverage. Sara Bryan sara@sevenoaksre.com Director/Vice-President/Secretary Boone Boone United States Anthony Calek Craig Christensen Signed
768 2023-09-12 12:48 Anonymous (not verified) 94.188.207.224 BSSI MW 23959 580th 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. 2023-08-28 Tom Barragy tom@agvolution.co Ames Boone Iowa Blaine Bancks Pete Romig Signed (1) The corporation rejects the employers’ liability coverage. Thomas j Barragy tbarragy@agvolution.co ownet AMES Boone ia Blaine Bancks Pete Romig Signed
863 2024-01-23 13:59 Anonymous (not verified) 94.188.205.176 United Marble & Tile, Inc. 915 8th Street, #201, Boone, IA. 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-24 Albert James Gotta jim@umtile.com Slater Boone IA Antonina M Gotta MARY KATE RUSSELL Signed (1) The corporation rejects the employers’ liability coverage. Albert James Gotta jim@umtile.com President Sole Share Holder Boone IA IA Antonina M Gotta Antonina M Gotta Signed
412 2022-02-23 15:42 Anonymous (not verified) 208.126.112.220 Bergmann Bros. Excavating & Trucking PO Box G, Frederika, IA 50631 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. 2022-02-23 Kenny A. Bergmann kennb@butler-bremer.com Frederika Bremer Iowa Ronald A. Bergmann Tad M. Chapin Signed (1) The corporation rejects the employers’ liability coverage. Kenny A. Bergmann kennb@butler-bremer.com self Frederika Bremer Iowa Ronald A. bergmann Tad M. Chapin Signed
605 2023-02-17 11:29 Anonymous (not verified) 94.188.207.223 McDonald Construction 617 Kingsley Ave, Waterloo Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-17 Todd Gelner toddandabbey@yahoo.com Denver Bremer Iowa Abbey Gelner Abbey Elizabeth-Anne Gelner Signed (1) The corporation rejects the employers’ liability coverage. Todd Gelner toddandabbey@yahoo.com Self Denver Bremer Iowa Abbey Gelner Karen Henry Signed
779 2023-10-04 07:14 Anonymous (not verified) 94.188.207.225 CanD Homes, LLC 1147 Leitha Ter, Waverly, IA 50677 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-04 Alexander Eckard-Lewis alex.lewis@candhomes.com Waverly Bremer IA Connor Eustice Victor Sanders Signed (1) The corporation rejects the employers’ liability coverage. Alexander Eckard-Lewis alex.lewis@candhomes.com Vice President Waverly Bremer IA Connor Eustice Victor Sanders 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
214 2021-03-28 12:59 Anonymous (not verified) 172.86.34.18 Agronomic Solutions, INC 1614 Fir Avenue Coon Rapids, IA 50058 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-28 Nickolas Lee Steffens nsteffens@agsolutionsinc.net Quasqueton Buchanan Iowa Julia Sperfslage Andrew Sperfslage Signed (1) The corporation rejects the employers’ liability coverage. Nickolas Lee Steffens nsteffens@agsolutionsinc.net Owner/ Vice President Quasqueton Buchanan Iowa Andrew Sperfslage Julia Sperfslage Signed
464 2022-05-06 10:15 Anonymous (not verified) 172.86.44.178 Cornhill Express LLC 6472 40th St, Aurora, IA 50607 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-06 Jamie Fettkether sales@cherepair.com Aurora Buchanan Iowa Ben Hogan Ryan Peyton Signed (1) The corporation rejects the employers’ liability coverage. Jamie Fettkether sales@cherepair.com Owner Aurora Buchanan Iowa Ben Hogan Ryan Peyton Signed
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
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
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
338 2021-09-22 10:34 Anonymous (not verified) 216.81.153.249 APS LLC 904 Lake 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. 2021-09-22 Amrit Singh amritaust1@gmail.com Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Amrit Singh amritaust1@gmail.com Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
372 2021-12-09 14:17 Anonymous (not verified) 204.155.61.217 Buena Vista Auto Sales Inc 1030 Lake Ave, Storm Lake, IA 50588 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-12-09 Arturo Lozano bvusedcars@siouxland.com Storm Lake Buena Vista IA Jared Brashears Michelle Munoz Signed (1) The corporation rejects the employers’ liability coverage. Arturo Lozano bvusedcars@siouxland.com Owner storm Lake Buena Vista IA Jared Brashears Michelle Munoz Signed
724 2023-08-02 16:09 Anonymous (not verified) 94.188.207.223 Magnussen Bros Inc 1945 560th Street, Newell, IA 50568 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-02 Duane Magnussen dcmag@ncn.net Newell Buena Vista Iowa Jared Brashears Katie Gunkelman Signed (1) The corporation rejects the employers’ liability coverage. Duane Magnussen ncmag@ncn.net Owner Newell Buena Vista IA Jared Brashears Katie Gunkelman Signed
973 2024-05-03 11:24 Anonymous (not verified) 94.188.207.227 Trent Hatlen 1042 490th Street, Rembrandt, IA 50576 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-03 Trent Hatlen trentgotti@yahoo.com Rembrandt Buena Vista Iowa Jared Brashears Katie Gunkelman Signed (1) The corporation rejects the employers’ liability coverage. Trent Hatlen trentgotti@yahoo.com Owner Rembrandt Buena Vista Iowa Jared Brashears Katie Gunkelman Signed
965 2024-04-30 10:47 Anonymous (not verified) 94.188.205.177 Billy Dudock 148818 Argo Fay Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-30 Billy Dudock mitzi@bruggemanlumber.com Thompson Carroll IL Roger Gibbs Mitzi Hoeger Signed (1) The corporation rejects the employers’ liability coverage. Billy Dudock mitzi@bruggemanlumber.com Self Thompson Carroll Il Roger Gibbs Mitzi Hoeger Signed
570 2022-11-16 10:35 Anonymous (not verified) 50.81.253.108 XU's Golden Dragon 508 Chestnut St., Atlantic, IA 50022 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-16 Xu Long 125529647@QQ.COM Atlantic Cass IA Richard Crall Shannon Crall Signed (1) The corporation rejects the employers’ liability coverage. Richard Crall richard@partnersins.com Insurance Agent Atlantic Cass United States Shannon Crall Richard Crall Signed
571 2022-11-16 10:40 Anonymous (not verified) 50.81.253.108 XU's Golden Dragon 508 Chestnut St., Atlantic, IA 50022 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-16 Tingjie Huang 125529647@QQ.COM Atlantic Cass IA Richard Crall Shannon Crall Signed (1) The corporation rejects the employers’ liability coverage. Richard Crall richard@partnersins.com Insurance Agent Atlantic Cass United States Shannon Crall Richard Crall Signed
121 2020-10-01 09:40 Anonymous (not verified) 50.82.176.77 Kinion Towing Inc. 100 Industrial Park Drive, Clarence, IA 52216 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. 2020-09-30 Adam Kinion kinionas@yahoo.com Tipton Cedar Iowa Michael Blake Jeffrey Case Signed (1) The corporation rejects the employers’ liability coverage. Adam Kinion kinionas@yahoo.com Vice President Tipton Cedar Iowa Michael Blake Jeffrey Case Signed
472 2022-05-13 11:19 Anonymous (not verified) 69.18.19.139 BES, Inc. 1615 E Washington St, Mt Pleasant, IA 52641 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. 2022-05-13 Todd Baldridge todd.baldridge@beswatersolutions.com West Branch Cedar Iowa Nicholas Baldridge Owen Baldridge Signed (1) The corporation rejects the employers’ liability coverage. Randy Seberg randy.seberg@beswatersolutions.com Managing Director Mt Pleasant Henry IA John Rodewald Matt Mowery Signed
626 2023-03-16 11:18 Anonymous (not verified) 94.188.207.224 Raymond Carpenter 1655 230th St Tipton IA 52772 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. 2023-03-16 Raymond Carpenter badseedmudraching@gmail.com Tipton Cedar Iowa Mitzi Hoeger Roger Gibbs Signed (1) The corporation rejects the employers’ liability coverage. Raymond Carpenter badseedmudracing@gmail.com Self Tipton Cedar IA Roger Gibbs Mitzi Hoeger Signed
713 2023-07-25 12:26 Anonymous (not verified) 94.188.205.174 HT&T Drywall 479 old lincoln hwy Mechanicsville Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-25 Tracy Spray tspray9@hotmail.com Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed (1) The corporation rejects the employers’ liability coverage. Tracy Spray tspray9@hotmail.com Owner Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed
718 2023-07-27 08:43 Anonymous (not verified) 94.188.207.225 HT&T Drywall 479 Old Lincoln Hwy I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-27 Tracy Spray tspray9@hotmail.com Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed (1) The corporation rejects the employers’ liability coverage. Tracy Spray tspray9@hotmail.com Owner Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed
813 2023-11-14 13:00 Anonymous (not verified) 94.188.207.226 NeX Level Moving, LLC 5634 Deerwood St. SW, Cedar Rapids, IA, 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-14 Garrett Allen Reno garrettreno2001@gmail.com Tipton Cedar Iowa Bridget Camp Tarin Erenberger Signed (1) The corporation rejects the employers’ liability coverage. Tarin Erenberger tarin.nexlevelusa@gmail.com Operations Director Cedar Rapids Linn Iowa Bridget Camp Garrett Reno Signed
814 2023-11-14 13:11 Anonymous (not verified) 94.188.207.225 NeX Level Moving, LLC 5634 Deerwood St. SW, Cedar Rapids, IA, 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-14 Garrett Allen Reno garrettreno2001@gmail.com Tipton Cedar Iowa Bridget Camp Tarin Erenberger Signed (1) The corporation rejects the employers’ liability coverage. Garrett Reno garrettreno2001@gmail.com Self Tipton Cedar Iowa Bridget Camp Tarin Erenberger Signed
899 2024-02-25 18:18 Anonymous (not verified) 94.188.207.229 Michael D Clark 324 main st Bennett Iowa 52721 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-25 Michael D Clark michaeld3705@gmail.com Bennett Cedar Iowa Davia Dawn Kelley Tabetha Jean Widmer Signed (1) The corporation rejects the employers’ liability coverage. Michael D Clark michaeld3705@gmail.com Owner Bennett Cedar Iowa Davia Dawn Kelley Tabetha Jean Widmer Signed
906 2024-02-29 16:16 Anonymous (not verified) 94.188.205.168 Bradley K. Gaul Handyman Services 740 Cedar Valley Road, Tipton, IA 52772 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-29 Bradley Keith Gaul bjgjal33@aol.com Tipton Cedar Iowa Jill Lynette Gaul Logan Benjamin Gaul Signed (1) The corporation rejects the employers’ liability coverage. Bradley Keith Gaul bjgjal33@aol.com Self Tipton Cedar Iowa Jill Lynette Gaul Logan Benjamin Gaul Signed
907 2024-03-01 12:13 Anonymous (not verified) 94.188.207.230 Bulls Eye Builders Llc 406 E South st Mechanicsville Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-01 Timothy Hansel bullseyebuildersllc@gmail.com Mechanicsville Cedar Iowa Kevin Kofron Jackie hart Signed (1) The corporation rejects the employers’ liability coverage. Timothy Hansel bullseyebuildersllc@gmail.com Owner Mechanicsville Iowa United States Kevin Kofron Jackie Hart Signed
83 2020-05-20 12:34 Anonymous (not verified) 108.171.131.188 North Iowa Custom Seamless Guttering, Inc PO Box 512, 1300 2nd Ave S, Clear Lake, Iowa 50428 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. 2020-05-20 Keith E Main keithmaincsg@hotmail.com Clear Lake Cerro Gordo Iowa Lloyd L Heinselman Diane K Harrington Signed (1) The corporation rejects the employers’ liability coverage. Keith E Main keithmaincsg@hotmail.com President Clear Lake Cerro Gordo Iowa Lloyd L Heinselman Diane K Harrington Signed
233 2021-04-13 10:35 Anonymous (not verified) 172.83.18.1 Skyway Inc 7030 27th Way, Clear Lake, IA 50428 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. 2021-03-06 Brad Thompson mary@skywaypropertyinspections.com Clear Lake Cerro Gordo Iowa Becky Plagge Deb Otto Signed (1) The corporation rejects the employers’ liability coverage. Brad Thompson mary@skywaypropertyinspections.com Owner Clear Lake Cerro Gordo Iowa Becky Plagge Deb Otto Signed
234 2021-04-13 10:37 Anonymous (not verified) 172.83.18.1 Skyway Inc 7030 27th Way, Clear Lake, IA 50428 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. 2021-03-06 Mary Thompson mary@skywaypropertyinspections.com Clear Lake Cerro Gordo Iowa Becky Plagge Deb Otto Signed (1) The corporation rejects the employers’ liability coverage. Brad Thompson mary@skywaypropertyinspections.com Owner Clear Lake Cerro Gordo Iowa Becky Plagge Deb Otto Signed
245 2021-04-22 10:54 Anonymous (not verified) 172.83.18.1 Skyway Inc 7030 27th Way, Clear Lake, IA 50428 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. 2021-04-22 Brad Thompson becky@fgains.com Clear Lake Cerro Gordo Iowa Debbie Otto Paxton Farmer Signed (1) The corporation rejects the employers’ liability coverage. Brad Thompson becky@fgains.com Owner Clear Lake Cerro Gordo Iowa Debbie Otto Paxton Farmer Signed
246 2021-04-22 10:56 Anonymous (not verified) 172.83.18.1 Skyway Inc 7030 27th Way, Clear Lake, IA 50428 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. 2021-04-22 Mary Thompson becky@fgains.com Clear Lake Cerro Gordo Iowa Debbie Otto Paxton Farmer Signed (1) The corporation rejects the employers’ liability coverage. Brad Thompson becky@fgains.com Owner Clear Lake Cerro Gordo Iowa Debbie Otto Paxton Farmer Signed