736 |
2023-08-10 11:28 |
Anonymous (not verified) |
94.188.205.169 |
Johnson Custom Paint & Design |
1414 N 9th 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. |
2023-08-10 |
Joshua Johnson |
johnsoncustompaint@hotmail.com |
Fort Dodge |
Webster |
Iowa |
Jacklyn Johnson |
Roger Johnson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joshua Johnson |
johnsoncustompaint@hotmail.com |
Owner |
Fort Dodge |
Webster |
Iowa |
Jacklyn Johnson |
Roger Johnson |
Signed |
751 |
2023-08-21 09:18 |
Anonymous (not verified) |
94.188.205.168 |
Johnson Custom Paint and Design LLC DBA Mid-century Sign Company |
1414 N 9th street Fort Dodge, Iowa 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. |
2023-08-21 |
Joshua Johnson |
johnsoncustompaint@hotmail.com |
Fort Dodge |
Webster |
Iowa |
Jacklyn Johnson |
Roger Johnson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joshua Johnson |
johnsoncustompaint@hotmail.com |
Owner |
Fort Dodge |
webster |
Iowa |
Jacklyn Johnson |
Roger Johnskn |
Signed |
752 |
2023-08-21 14:04 |
Anonymous (not verified) |
94.188.205.177 |
Johnson Custom Paint and Design, LLC |
1414 N 9th street Fort Dodge Iowa 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. |
2023-08-21 |
Joshua Johnson |
jackiejohnson1251@gmail.com |
Fort dodge |
Webster |
Iowa |
Jacklyn Johnson |
Roger Johnson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jacklyn Johnson |
jackiejohnson1251@gmail.com |
Wife |
Fort dodge |
Webater |
Iowa |
Jacklyn Johnson |
Roger Johnson |
Signed |
237 |
2021-04-14 15:00 |
Anonymous (not verified) |
75.89.76.245 |
Pillar Inc. |
906 W. 18th Street, Bldg A, Nevada, Iowa 50201 |
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 |
Matthew Paul Klucas |
matt@pillariowa.com |
Fort Dodge |
Webster County |
Iowa |
Wendy Bergeson |
Riley Abel |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Matthew Paul Klucas |
matt@pillariowa.com |
Owner |
Fort Dodge |
Webster County |
Iowa |
Wendy Bergeson |
Riley Abel |
Signed |
710 |
2023-07-21 08:26 |
Anonymous (not verified) |
94.188.205.169 |
Dream Team Anesthesia, Inc. |
2800 E. Enterprise Ave, Ste 333, Appleton, WI 54913 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-21 |
Jesse Chiu |
jessechiu2@yahoo.com |
Sterling |
Whiteside |
IL |
Joseph Chiu |
Kin Chiu |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jesse Chiu |
jessechiu2@yahoo.com |
President |
Waterloo |
Polk |
Iowa |
Joseph Chiu |
Kin Chiu |
Signed |
126 |
2020-10-28 14:31 |
Anonymous (not verified) |
104.207.25.44 |
Little Bison Daycare Center |
404 2nd St. NW Buffalo Center, IA 50424 |
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. |
2020-10-28 |
Cody Tyler Wirtjes |
cody@afschem.com |
Buffalo Center |
Winnebago |
Iowa |
Michael James Perkins |
Garrett Alan Asmus |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cody Tyler Wirtjes |
cody@afschem.com |
Board President |
Buffalo Center |
Winnebago |
Iowa |
Michael James Perkins |
Garrett Alan Asmus |
Signed |
130 |
2020-11-02 12:40 |
Anonymous (not verified) |
67.55.220.86 |
Little Bison Childcare Center |
404 2nd St NW, Buffalo Center, IA 50424 |
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. |
2020-11-02 |
Joseph Robert Angstman |
angstman.joe@gmail.com |
Buffalo Center |
Winnebago |
Iowa |
Emily Jean Thomsen Angstman |
Pamela Kay Angstman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Robert Angstman |
angstman.joe@gmail.com |
Secretary |
Buffalo Center |
Winnebago |
Iowa |
Emily Jean Thomsen Angstman |
Pamela Kay Angstman |
Signed |
131 |
2020-11-03 10:26 |
Anonymous (not verified) |
207.32.1.185 |
Little Bison Childcare Center |
404 2nd ST NW Buffalo Center, IA. 50424 |
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. |
2020-11-03 |
Megan C Holland |
megzholland@live.com |
Buffalo Center |
Winnebago |
Iowa |
Nicholas D Holland |
Emily J Angstman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Megan C Holland |
megzholland@live.com |
Vice President |
Buffalo Center |
Winnebago |
Iowa |
Nicholas D Holland |
Emily J Angstman |
Signed |
545 |
2022-09-29 08:59 |
Anonymous (not verified) |
208.126.212.128 |
City of Leland |
316 Walnut St., Leland, IA 50453 |
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. |
2022-09-29 |
Marsha Casler |
mandrcasler@hotmail.com |
Leland |
Winnebago |
Iowa |
Roger Torkelson |
Kelly Bendickson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dawn Arispe |
leland@wctatel.net |
City Clerk of Leland |
Leland |
Iowa |
United States |
Roger Torkelson |
Kelly Bendickson |
Signed |
546 |
2022-09-29 09:02 |
Anonymous (not verified) |
208.126.212.128 |
City of Leland |
316 Walnut St., PO Box 127 Leland, IA 50453 |
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. |
2022-09-29 |
Susan Krein |
skkrein@gmail.com |
Leland |
Winnebago |
Iowa |
Roger Torkelson |
Kelly Bendickson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dawn Arispe |
leland@wctatel.net |
City of Leland City Clerk |
Leland |
Winnebago |
Iowa |
Roger Torkelson |
Kelly Bendickson |
Signed |
547 |
2022-09-29 09:04 |
Anonymous (not verified) |
208.126.212.128 |
City of Leland |
316 Walnut St., PO Box 127, Leland, IA 50453 |
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. |
2022-09-29 |
Ken Steil |
leland@wctatel.net |
Leland |
Winnebago |
Iowa |
Roger Torkelson |
Kelly Bendickson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dawn Arispe |
leland@wctatel.net |
City of Leland City Clerk |
Leland |
Winnebago |
Iowa |
Roger Torkelson |
Kelly Bendickson |
Signed |
548 |
2022-09-29 09:06 |
Anonymous (not verified) |
208.126.212.128 |
City of Leland |
316 Walnut St., PO Box 127, Leland, IA 50453 |
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. |
2022-09-29 |
Rex Johnson |
rexr@wctatel.net |
Leland |
Winnebago |
Iowa |
Roger Torkelson |
Kelly Bendickson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dawn Arispe |
leland@wctatel.net |
City of Leland City Clerk |
Leland |
Winnebago |
Iowa |
Roger Torkelson |
Kelly Bendickson |
Signed |
549 |
2022-09-29 09:08 |
Anonymous (not verified) |
208.126.212.128 |
City of Leland |
316 Walnut St., PO Box 127, Leland, IA 50453 |
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. |
2022-09-29 |
Jesse O'Toole |
jesseotoole7@gmail.com |
Leland |
Winnebago |
Iowa |
Roger Torkelson |
Kelly Bendickson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dawn Arispe |
leland@wctatel.net |
City of Leland City Clerk |
Leland |
Winnebago |
Iowa |
Roger Torkelson |
Kelly Bendickson |
Signed |
550 |
2022-09-29 09:10 |
Anonymous (not verified) |
208.126.212.128 |
City of Leland |
316 Walnut St., PO Box 127, Leland, IA 50453 |
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. |
2022-09-29 |
Russell Leitz |
rkleitz@wctatel.net |
Leland |
Winnebago |
Iowa |
Roger Torkelson |
Kelly Bendickson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dawn Arispe |
leland@wctatel.net |
City of Leland City Clerk |
Leland |
Winnebago |
Iowa |
Roger Torkelson |
Kelly Bendickson |
Signed |
575 |
2022-11-18 14:01 |
Anonymous (not verified) |
204.155.61.217 |
County Line Drainage Inc |
806 Milton Ave, Lake Mills, IA 50450 |
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. |
2022-11-18 |
Brian Helgeson |
dgust@mbtbank.com |
Lake Mills |
Winnebago |
Iowa |
Douglas Gust |
Lee Lambert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brian Helgeson |
brianshelgeson@gmail.com |
President |
Lake mills |
Winnebago |
Iowa |
Douglas Gust |
Lee Lambert |
Signed |
747 |
2023-08-19 15:30 |
Anonymous (not verified) |
94.188.207.229 |
Arneson Tree Service |
901 s Washington st Lake Mills IOWA 50450 |
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. |
2023-08-19 |
Charles Douglas Arneson |
charles.arneson@aol.com |
Lake Mills |
Winnebago |
IOWA |
Amber Arneson |
Carter Arneson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Charles Douglas Arneson |
charles.arneson@aol.com |
Owner |
Lake Mills |
Winnebago |
IOWA |
Amber arneson |
Carter Arneson |
Signed |
963 |
2024-04-29 17:42 |
Anonymous (not verified) |
94.188.207.227 |
Total Construction Inc |
4607 S Ridge Rd Sioux City IA 51106 |
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. |
2024-04-29 |
Daniel J Jennett II |
dj_jennett@hotmail.com |
Sioux City |
Woobury |
IA |
Julia L Lesko |
Olivia J Lesko |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel J Jennett II |
dj_jennett@hotmail.com |
President |
Sioux City |
Woodbury |
IA |
Julia L Lesko |
Olivia J Lesko |
Signed |
252 |
2021-05-04 13:47 |
Anonymous (not verified) |
159.242.43.24 |
J. Fox Distributing, Inc |
3801 Pierce Street, Sioux City, IA 51104 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-04 |
Joseph Fox |
huskerjoe12@gmail.com |
Sioux City |
Woodbury |
IA |
Jenny McIntyre |
Alex Meier |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Fox |
huskerjoe12@gmail.com |
President |
Sioux City |
Woodbury |
IA |
Jenny McIntyre |
Alex Meier |
Signed |
305 |
2021-08-08 17:02 |
Anonymous (not verified) |
24.119.190.239 |
Shawn Smalls Painting Inc |
2736 South Cedar Street, Sioux City, IA 51106 |
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. |
2021-08-08 |
David Shawn Small |
smallspaintingsc@gmail.com |
Sioux City |
Woodbury |
Iowa |
Douglas Wiliam Ball |
Ruth Elaine Ball |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Shawn Small |
smallspaintingsc@gmail.com |
Owner |
SIoux City |
Woodbury |
Iowa |
Douglas William Ball |
Ruth Elaine Ball |
Signed |
313 |
2021-08-19 10:28 |
Anonymous (not verified) |
216.81.153.249 |
Bailey01 LLC |
3020 S Cypress, Sioux City, IA 51106 |
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. |
2021-08-19 |
Gordon Hagen |
gordonhagen1@outlook.com |
Sioux City |
Woodbury |
Iowa |
Jared Brashears |
Mary Jo Olthoff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gordon Hagen |
gordonhagen1@outlook.com |
Owner |
Sioux City |
Woodbury |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
340 |
2021-10-01 15:44 |
Anonymous (not verified) |
3.217.29.203 |
Tracy Countryman |
745 Robert Drive Moville, IA 51039 |
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. |
2021-09-30 |
Tracy Countryman |
Tracycountryman@ymail.com |
Moville |
Woodbury |
Iowa |
Deborah Clark |
Jane Ashley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tracy Countryman |
Tracycountryman@ymail.com |
President |
Moville |
Woodbury |
Iowa |
Deborah Clark |
Jane Ashley |
Signed |
737 |
2023-08-10 21:39 |
Anonymous (not verified) |
94.188.207.224 |
fixIT.fyi, LLC |
1243 Buchanan Ave, Sioux City, IA 51108 |
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. |
2023-08-10 |
Daisy Larae Neuroth |
Daisy@fixIT.fyi |
Sioux City |
Woodbury |
Iowa |
Chad Neuroth |
Alice Bruns |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daisy Larae Neuroth |
Daisy@fixIT.fyi |
Owner/Same |
Sioux City |
Woodbury |
Iowa |
Chad Neuroth |
Alice Bruns |
Signed |
867 |
2024-01-24 15:04 |
Anonymous (not verified) |
94.188.207.227 |
Shook Handyman |
2415 Plum Creek 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. |
2024-01-24 |
Nolan Shook |
office@shookhandyman.com |
Sioux City |
Woodbury |
IA |
McKenna Warner |
Jessica Shook |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Susan Geist |
sgeist@paychex.com |
Paychex Insurance Agency Inc |
Rochester |
Monroe |
NY |
Nolan Shook |
McKenna Warner |
Signed |
956 |
2024-04-12 14:23 |
Anonymous (not verified) |
205.221.255.62 |
All things power wash ATP LLC |
2730 Lafayette, Sioux City, IA 51104 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-12 |
Anthony Rowe |
allthingspowerwash4usiouxcity@gmail.com |
Sioux City |
Woodbury |
Iowa |
Franzis Rios |
Tamara Bawi |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Anthony Rowe |
allthingspowerwash4usiouxcity@gmail.com |
Owner |
Sioux City |
Woodbury |
Iowa |
Franzis Rios |
Tamara Bawi |
Signed |
362 |
2021-11-16 11:20 |
Anonymous (not verified) |
63.227.65.43 |
F&H Aluminum, Inc. |
101 E. Corporate Drive Charles City, Iowa 50616 |
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. |
2021-11-16 |
DeWayne Ferch |
fhaluminum@netconx.net |
Kensett |
Worth |
Iowa |
Tom Stephany |
Amanda Korenberg |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
DeWayne Ferch |
fhaluminum@netconx.net |
President |
Kensett |
Worth |
Iowa |
Tom Stephany |
Amanda Korenberg |
Signed |
160 |
2021-01-13 10:52 |
Anonymous (not verified) |
173.190.64.239 |
united workers inc |
711 4th st ne |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-13 |
mayra sapolvada |
buck@trvnet.net |
Belmond |
wright |
iowa |
shannon muhlenbruch |
Martha Leal |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
mayra sapulvada |
buck@trvnet.net |
president |
belmond |
wright |
ia |
shannon myhlenbruch |
martha leal |
Signed |
208 |
2021-03-16 16:19 |
Anonymous (not verified) |
204.155.61.217 |
AGSPIRE INC |
1310 Kathryn Ct Buffalo, MN 55313 |
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. |
2021-02-02 |
Kent Kiebelkorn |
kent@hailmayday.com |
Buffalo |
Wright County |
Minnesota |
Docusign |
Docusign |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
unknown |
akraft@millerhartwig.com |
Unknown |
unknown |
unknown |
unknown |
unknown |
unknown |
Signed |
210 |
2021-03-22 15:20 |
Anonymous (not verified) |
204.155.61.217 |
Agspire Inc |
1310 Kathryn Ct Buffalo, MN 55313 |
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. |
2021-02-05 |
Kent Fiebelkorn |
kent@hailmayday.com |
Buffalo |
Wright County |
Minnesota |
DocuSign |
Ashley Kraft |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kent Fiebelkorn |
kent@hailmayday.com |
Owner |
Buffalo |
Wright County |
Minnesota |
DocuSign |
Ashley Kraft |
Signed |