586 |
2022-12-16 15:53 |
Anonymous (not verified) |
184.184.197.146 |
Halide Biologics |
330 Golfview Ave, Iowa City IA 52246 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-12-15 |
Daniel Infield |
danielinfield@gmil.com |
Bennington |
Douglas |
Nebraska |
Alexander Estell |
Jesse Herrera |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Infield |
danielinfield@gmail.com |
President |
Bennington |
NE |
United States |
Alexander Estell |
Jesse Herrera |
Signed |
53 |
2020-03-30 11:09 |
Anonymous (not verified) |
45.42.5.219 |
Taylor's Tri-State Construction |
660 Tanzanite Drive, Dubuque, IA 52001 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-03-06 |
John Taylor |
taylorsconstruction78@yahoo.com |
Dubuque |
Dubuque |
Iowa |
Brenda Lewis |
Jessica Stepp |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Taylor |
taylorsconstruction78@yahoo.com |
Co-owners |
Dubuque |
Dubuque |
Iowa |
Brenda Lewis |
Jessica Stepp |
Signed |
76 |
2020-05-04 10:24 |
Anonymous (not verified) |
173.191.207.202 |
Tim Fitzgerald Mechanical Services, Inc. |
724 1st Ave W - Dyersville, IA 52040 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-24 |
Tim Fitzgerald |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent-English Insurance |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
80 |
2020-05-11 12:29 |
Anonymous (not verified) |
173.191.207.202 |
J&D Furniture-Land Corp |
144 1st Ave East - Dyersville, IA 52040 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-05-07 |
Scott Hittenmiller |
dparsons@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
agent-English Insurance |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
82 |
2020-05-18 15:16 |
Anonymous (not verified) |
184.80.177.137 |
Farmers Best Popcorn, LLC |
110 1st Street North, - Worthington, IA 52078 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-05-18 |
Jon Ramaekers |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
self |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
103 |
2020-07-23 09:23 |
Anonymous (not verified) |
184.80.177.137 |
Jacob Reiff |
15738 N Cascade Rd - Peosta, IA 52068 |
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. |
2020-07-23 |
Jacob Reiff |
jheims@engish-insurance.com |
Peosta, |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
owner |
Peosta |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
109 |
2020-08-24 14:41 |
Anonymous (not verified) |
74.84.91.178 |
Rotten Love LLC |
1101 Valentine Drive, Dubuque, IA 52003 |
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. |
2020-08-14 |
Carolyn Schmid |
rottenlovellc@gmail.com |
Dubuque |
Dubuque |
Iowa |
Brenda Lewis |
Sue Miller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carolyn Schmid |
rottenlovellc@gmail.com |
partner |
Dubuque |
Dubuque |
IA |
Brenda Lewis |
Sue Miller |
Signed |
110 |
2020-08-25 14:31 |
Anonymous (not verified) |
199.241.229.222 |
Ney Trucking Inc |
5070 Wolff Rd Dubuque, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-08-25 |
Marvin L Ney |
marvin@paramountems.com |
Peosta |
Dubuque |
Iowa |
Karen Ludovissy |
Brenda Weatherwax |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Maria A Ney |
maria@paramountems.com |
Secretary |
Peosta |
Dubuque |
IA |
Karen Ludovissy |
Brenda Weatherwax |
Signed |
128 |
2020-10-29 07:51 |
Anonymous (not verified) |
74.84.91.178 |
J & J Drywall LLC |
1277 Elm Street |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-10-27 |
Jeff Frick |
frickdbq@gmailc.com |
Dubuque |
Dubuque |
IA |
Brenda Lewis |
Gabe Drewelow |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeff Frick |
frickdbq@gmailc.com |
president |
Dubuque |
Dubuque |
Iowa |
Brenda Lewis |
Gabe Drewelow |
Signed |
129 |
2020-10-30 11:23 |
Anonymous (not verified) |
184.80.177.137 |
Haberdash Outfitters, Inc. |
109 1st Ave East - Dyersville, IA 52040 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-10-27 |
Jennifer Recker |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
135 |
2020-11-20 11:05 |
Anonymous (not verified) |
208.95.1.97 |
Burds Communities Inc. |
606 S 3rd Street, Bellevue, IA 52031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-11-20 |
Todd Burds |
burdshousing@yahoo.com |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Todd Burds |
burdshousing@yahoo.com |
President |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
136 |
2020-11-20 11:06 |
Anonymous (not verified) |
208.95.1.97 |
Burds Communities Inc. |
606 S 3rd Street, Bellevue, IA 52031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-11-20 |
Tim Burds |
burdshousing@yahoo.com |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tim Burds |
burdshousing@yahoo.com |
Vice President |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
146 |
2020-12-22 08:48 |
Anonymous (not verified) |
207.155.115.120 |
Kafer Lawn Care |
206 frentress dr Farley, IA 52046 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-22 |
Benjamin Terry Hayes |
benhayes1800@gmail.com |
Epworth |
Dubuque |
IA |
Adam Kafer |
Jeffery Sisler |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Benjamin Terry Hayes |
benhayes1800@gmail.com |
Owner |
Epworth |
Dubuque |
IA |
Adam Kafer |
Jeffery Sisler |
Signed |
167 |
2021-01-26 11:56 |
Anonymous (not verified) |
74.84.91.178 |
Shea Real Estate LLC |
135 Devon Drive, Dubuque, IA 52001 |
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. |
2020-12-17 |
Lucas Kahl |
shearealestatellc@gmail.com |
Dubuque |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lucas Kahl |
shearealestatellc@gmail.com |
President |
Dubuque |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
168 |
2021-01-26 12:06 |
Anonymous (not verified) |
74.84.91.178 |
RAM Services |
13276 Harvest Mood Ridge, Sherrill, IA 52073 |
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. |
2020-12-11 |
Dusty Herbst |
dustyherbst@hotmail.com |
Sherrill |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dusty Herbst |
dustyherbst@hotmail.com |
President |
Sherrill |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
169 |
2021-01-26 12:20 |
Anonymous (not verified) |
74.84.91.178 |
Sunset Ridge Winery LLC |
12615 Highway 52 North, Dubuque, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-07 |
John Bonnette |
jbonnette@yahoo.com |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Bonnette |
jbonnette@yahoo.com |
Officer |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
170 |
2021-01-26 12:23 |
Anonymous (not verified) |
74.84.91.178 |
Sunset Ridge Winery LLC |
12615 Highway 52 North, Dubuque, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-07 |
Ann Bonnette |
jbonnette@yahoo.com |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ann Bonnette |
jbonnette@yahoo.com |
Officer |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
205 |
2021-03-10 09:55 |
Anonymous (not verified) |
173.27.221.9 |
Tri State Archery, Inc |
2100 White St, Dubuque IA 52001 |
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. |
2020-12-14 |
Denise Udelhofen |
office@tristateoutdoors.net |
Dubuque |
Dubuque |
Iowa |
Phillip J Meyer |
Debbie Meyer |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jeff Udelhofen |
office@tristateoutdoors.net |
President |
Dubuque |
Dubuque |
IA |
Phillip Meyer |
Debbie Meyer |
Signed |
232 |
2021-04-12 11:14 |
Anonymous (not verified) |
74.84.91.178 |
Heim Enterprises LLC |
13532 Mueller Parkway, Sherrill, IA 52073 |
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. |
2021-04-01 |
Cory Heim |
corypheim@gmail.com |
Sherrill |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Cory Heim |
corypheim@gmail.com |
owner |
Sherrill |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
279 |
2021-06-23 10:41 |
Anonymous (not verified) |
184.80.177.137 |
AA Breeders |
P.O. Box 470 - Epworth, IA 52045 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-22 |
Justin Curtis |
jheims@english-insurance.com |
Epworth |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
AA Breeders - Justin Curtis |
jheims@english-insurance.com |
self |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
334 |
2021-09-14 16:24 |
Anonymous (not verified) |
67.129.252.2 |
Nextec |
4050 Westmark Drive, Dubuque, Iowa 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-14 |
Susan Kern |
skern@kendallhunt.com |
Dubuque |
Dubuque |
Iowa |
Paul Kern |
Matthew Johnston |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Greg Feltes |
gfeltes@westmarkdevelopment.com |
Officer |
Dubuque |
Dubuque |
Iowa |
Dana Feltes |
Cole Feltes |
Signed |
375 |
2021-12-23 12:23 |
Anonymous (not verified) |
66.230.245.47 |
W. R. Elliot & Associates, Ltd. |
3306 Brook Hollow Dr, Asbury, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-12-23 |
William R. Elliot |
bill@wreassoc.com |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L. Spalla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William R. Elliot |
bill@wreassoc.com |
President |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
376 |
2021-12-29 14:40 |
Anonymous (not verified) |
66.230.245.47 |
W. R. Elliot & Associates, Ltd. |
3306 Brook Hollow Dr, Asbury, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-12-29 |
Karen R. Elliot |
karen@handiwerks.com |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William R. Elliot |
bill@wreassoc.com |
President |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
384 |
2022-01-06 16:01 |
Anonymous (not verified) |
184.80.177.137 |
Top R Farms |
1199 Woodland Drive - Dyersville, IA 52040 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-06 |
Robert Fangmann |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
388 |
2022-01-11 13:58 |
Anonymous (not verified) |
184.80.177.137 |
Demmer Construction |
203 Michigan Ave - Farley, IA 52046 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-12-21 |
Charlie Demmer |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jenny Osburn |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
389 |
2022-01-11 14:02 |
Anonymous (not verified) |
184.80.177.137 |
Demmer Construction |
203 Michigan Ave - Farley, IA 52046 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-12 |
Charlie Demmer |
jheims@english-insurance.com |
Farley |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jenny Osburn |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
413 |
2022-02-23 16:31 |
Anonymous (not verified) |
184.80.177.137 |
T-Rex Hospitality LLC, DBA FUSE |
120 Twin Steeples Circle, Dyersville 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. |
2022-02-23 |
Tara Rahe |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
424 |
2022-03-11 15:36 |
Anonymous (not verified) |
69.63.16.2 |
BR Flynn Co Inc |
16756 Corey Daniel Ct, Dubuque, IA 52001 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-11 |
Bruce R Flynn |
br.flynn4@gmail.com |
Dubuque |
Dubuque |
Iowa |
Rick Meyer |
Dyan Kriener |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bruce R Flynn |
br.flynn4@gmail.com |
President |
Dubuque |
Dubuque |
IA |
Rick Meyer |
Dyan Kriener |
Signed |
431 |
2022-03-25 15:47 |
Anonymous (not verified) |
199.241.229.222 |
Ney Trucking Inc |
5070 Wolff Rd Dubuque, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-25 |
Maria A Ney |
maria@neytrucking.com |
Peosta |
Dubuque |
IA |
Brenda Weatherwax |
Becky Schmelzer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Maria Ney |
maria@neytrucking.com |
President |
Peosta |
Dubuque |
IA |
Brenda Weatherwax |
Becky Schmelzer |
Signed |
432 |
2022-03-25 15:49 |
Anonymous (not verified) |
199.241.229.222 |
Ney Trucking Inc |
5070 Wolff Rd Dubuque, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-25 |
Marvin L Ney |
marvin@paramountems.com |
Peosta |
Dubuque |
IA |
Brenda Weatherwax |
Becky Schmelzer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Maria Ney |
maria@neytrucking.com |
President |
Peosta |
Dubuque |
IA |
Brenda Weatherwax |
Becky Schmelzer |
Signed |
436 |
2022-03-29 11:07 |
Anonymous (not verified) |
184.80.177.137 |
Adam Sheppard |
22194 260th St - Delhi, 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. |
2022-03-24 |
Adam Sheppard |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Sheppard |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
448 |
2022-04-19 15:15 |
Anonymous (not verified) |
184.80.177.137 |
Andrew Lemke DBA: TAP Fabrication |
27214 218th Street, Earlville, IA 52041 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-08 |
Andrew Lemke |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
455 |
2022-04-27 14:04 |
Anonymous (not verified) |
184.80.177.137 |
Classic Custom Cabinets, Inc |
31931 Bries Drive , Dyersville, IA 52040 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-27 |
Mike Then |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
541 |
2022-09-23 13:13 |
Anonymous (not verified) |
184.80.177.137 |
Tim & Lori Daly |
25430 New Vienna Rd - Farley, IA 52046 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-09-23 |
Tim Daly |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
729 |
2023-08-04 07:39 |
Anonymous (not verified) |
94.188.207.228 |
Barrel Head Winery Inc |
9995 Laudeville Road, Dubuque, IA 52003 |
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. |
2023-08-03 |
Aaron Fuhreck |
sales@barrelheadiowa.com |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Aaron Fuhreck |
sales@barrelheadiowa.com |
Owner |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
730 |
2023-08-04 07:42 |
Anonymous (not verified) |
94.188.207.225 |
Barrel Head Winery Inc |
9995 Laudeville Road, Dubuque, IA 52003 |
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. |
2023-08-03 |
Jodie Fuhreck |
sales@barrelheadiowa.com |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jodie Fuhreck |
sales@barrelheadiowa.com |
Owner |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
741 |
2023-08-15 12:03 |
Anonymous (not verified) |
94.188.205.176 |
The Ritz Restaurant, LLC |
232 1st Ave E - Dyersville, IA 52040 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-11 |
Megan Engstrom |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
jheims@english-insurance.com |
self |
Dyersville |
DUbuque |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
742 |
2023-08-15 12:06 |
Anonymous (not verified) |
94.188.205.175 |
The Ritz Restaurant, LLC |
232 1st Ave E - Dyersville, IA 52040 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-11 |
Dan Engstrom |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
jheims@english-insurance.com |
self |
Dyersville |
IA |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
859 |
2024-01-19 06:38 |
Anonymous (not verified) |
94.188.205.166 |
D & G Communications |
405 1st Street N. Farley, Iowa 52046 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-19 |
David William Hirsch |
dngcomm@hotmail.com |
Farley |
Dubuque |
Iowa |
Gina Hirsch |
Micki Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave Hirsch |
dngcomm@hotmail.com |
Owner |
Farley |
Dubuque |
Iowa |
Gina Hirsch |
Micki Jones |
Signed |
615 |
2023-02-28 08:15 |
Anonymous (not verified) |
94.188.207.224 |
River City Transport |
201 Lezlie 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. |
2023-02-28 |
Christopher Ryan Brewer |
chris@rivercitylogistics.net |
Peosta |
Dubuque County |
Iowa |
Brian Brewer |
Nicholas Lester |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chris Brewer |
chris@rivercitylogistics.net |
Owner |
Peosta |
Iowa |
United States |
Brian Brewer |
Nicholas Lester |
Signed |
186 |
2021-02-24 14:35 |
Anonymous (not verified) |
216.51.194.37 |
Estherville Aviation, Inc. |
1672 425th Ave, Estherville, IA 51334 |
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. |
2021-02-24 |
Paul Abrams Slaughter |
estavtn@yourstarnet.net |
Estherville |
Emmet |
Iowa |
Jordan Lampman |
Dwayne Hoss |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Abrams Slaughter |
estavtn@yourstarnet.net |
President |
Estherville |
Emmet |
Iowa |
Jordan Lampman |
Dwayne Hoss |
Signed |
196 |
2021-03-03 11:11 |
Anonymous (not verified) |
173.31.147.225 |
TLI INVESTMENTS INC |
1712 368TH AVE ESTHERVILLE, IA 51334 |
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. |
2021-02-15 |
LESLI IVERSON |
TBYRDLES@YAHOO.COM |
ESTHERVILLE |
EMMET |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LESLI IVERSON |
TBYRDLES@YAHOO.COM |
PRESIDENT |
ESTHERVILLE |
EMMET |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
197 |
2021-03-03 11:16 |
Anonymous (not verified) |
173.31.147.225 |
TLI INVESTMENTS INC |
1712 368TH AVE ESTHERVILLE, IA 51334 |
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. |
2021-02-15 |
TRACE IVERSON |
JOEL@WALKERINSURANCE.COM |
ESTHERVILLE |
EMMET |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
TRACE IVERSON |
TBYRDLES@YAHOO.COM |
VICE PRESIDENT |
ESTHERVILLE |
EMMET |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
201 |
2021-03-04 10:04 |
Anonymous (not verified) |
104.193.30.26 |
JDS TRANSFER, INC. |
22327 60TH ST, OELWEIN, IA 50662 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-04 |
AMANDA S. KOESTER |
STAMP210@HOTMAIL.COM |
OELWEIN |
FAYETTE |
IOWA |
KACIE DERR |
LEANNA STAMP |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
JACOB D STAMP |
STAMP210@HOTMAIL.COM |
PRESIDENT |
OELWEIN |
FAYETTE |
IOWA |
KACIE DERR |
LEANNA STAMP |
Signed |
314 |
2021-08-19 12:58 |
Anonymous (not verified) |
173.26.33.84 |
CLINK FM, INC. |
110 N. Maryville Street, 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. |
2021-08-19 |
Jesse Y Goplen |
jessegoplen@gmail.com |
Oelwein |
Fayette |
IA |
Della Nehring |
Tim Nehring |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kyana Taillon |
kyana@clink.fm |
Co-Founder/Vice-President |
Oelwein |
Fayette |
IA |
Della Nehring |
Tim Nehring |
Signed |
315 |
2021-08-19 13:08 |
Anonymous (not verified) |
173.26.33.84 |
CLINK FM, Inc. |
110 N. Maryville 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. |
2021-08-19 |
Kyana B Taillon |
kyanalily@gmail.com |
Oelwein |
Fayette |
IA |
Della Nehring |
Tim Nehring |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jesse Y Goplen |
jesse@clink.fm |
Co-Founder/President |
Oelwein |
Fayette |
IA |
Della Nehring |
Tim Nehring |
Signed |
536 |
2022-09-16 09:56 |
Anonymous (not verified) |
65.155.194.4 |
Tectum Construction and Roofing Inc. |
1623 Thetford Cir Orlando FL 32824 |
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. |
2022-09-16 |
Segundo Sanchez |
fsanchez@tectumconstruction.com |
Orlando |
Fl |
United States |
Chris Becker |
Dereck Bolten |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Segundo Sanchez |
fsanchez@tectumconstruction.com |
CEO |
ORLANDO |
Orange |
Florida |
Chris Becker |
Dereck Bolten |
Signed |
260 |
2021-05-06 11:12 |
Anonymous (not verified) |
76.79.44.61 |
Woltemath Farm Inc |
3096 300th 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. |
2021-05-06 |
Robert Allen Woltemath |
rwoltem@gmail.com |
Hamburg |
Fremont |
IA |
Lisa Reinier |
Sheryl Owen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandra Lynn Graybill |
sndygra@gmail.com |
Officer/Owner |
Council Bluffs |
Pottawattamie |
IA |
Lisa Reinier |
Sheryl Owen |
Signed |
261 |
2021-05-06 11:31 |
Anonymous (not verified) |
76.79.44.61 |
WOLTEMATH FARM INC |
3096 300TH AVE, Hamburg, IA 51640 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-06 |
Robert Allen Woltemath |
rwoltem@gmail.com |
Hamburg |
Fremont |
IOWA |
Lisa Reinier |
Sheryl Own |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandra Lynn Graybill |
sndygra@gmail.com |
Owner/ Officer |
Council Bluffs |
Pottawattamie |
IA |
Lisa Reinier |
Sheryl Owen |
Signed |
805 |
2023-10-31 14:53 |
Anonymous (not verified) |
94.188.207.225 |
PJ Trucking Unlimited LLC |
2617 380th 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. |
2023-10-31 |
Peggy Jensen |
pegandhalj@gmail.com |
Farragut |
Fremont |
Iowa |
Julie Marshall |
Darlene Carpenter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Peggy Jensen |
pegandhalj@gmail.com |
Member |
Farragut |
US |
US |
Julie Marshall |
Darlene Carpenter |
Signed |