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Rejection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Corporation: Address of Corporation Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Statement Agreement: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Agreement: Alternative Selection: Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Corporation of Authorized Agent: City of Residence: County of Residence: State: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
824 2023-11-21 13:22 Anonymous (not verified) 94.188.207.227 OhZone. LLC 852 Washington Street Burlington, IA 52601 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-19 Jeffery W Ishmael jeffishmael@gmail.com Des Moines IA United States Juan DeLlanos Gregory Gunter Signed (1) The corporation rejects the employers’ liability coverage. Jeffery W Ishmael jeffishmael@gmail.com Co-Owner Des Moines IA United States Juan DeLlanos Gregory Gunter Signed
829 2023-11-27 08:59 Anonymous (not verified) 94.188.207.224 Adam Ruess Masonry 206.w Elm 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. 2023-11-27 Adam Ruess ruess33@gmail.com Lone Tree IA United States Adam Ruess Adam Ruess Signed (1) The corporation rejects the employers’ liability coverage. Adam Ruess ruess33@gmail.com Owner Lone Tree IA United States Adam Ruess Adam Ruess Signed
831 2023-12-06 17:04 Anonymous (not verified) 94.188.205.167 PHOENIX CONSTRUCTION LLC 2219 E 13th St Des Moines, IA 50316 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. 2023-12-02 JUAN PABLO GUTIERREZ LEON jpgutierrez9000@yahoo.com Des Moines IA IA DAISY VASQUEZ Graciela Rodriguez Signed (1) The corporation rejects the employers’ liability coverage. arturo salgado fortworth@aksinsurance.com insured irving TX TX DAISY VASQUEZ DAISY VASQUEZ Signed
834 2023-12-13 08:35 Anonymous (not verified) 94.188.207.228 PHOENIX CONSTRUCTION LLC 2219 E 13TH ST DES MOINES, IA 50316 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. 2023-12-13 JUAN PABLO GUTIERREZ LEON jpgutierrez9000@yahoo.com DES MOINES IA IA DAISY VASQUEZ GRACIELA RODRIGUEZ Signed (1) The corporation rejects the employers’ liability coverage. ARTURO SALGADO commercial@aksinsurance.com Insured Irving TX TX DAISY VASQUEZ GRACIELA RODRIGUEZ Signed
838 2023-12-14 08:57 Anonymous (not verified) 94.188.207.223 Chuck Amling 807 Main Street, Garber IA 52048 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. 2023-12-14 Chuck Amling mitzi@bruggemanlumber.com Garber IA United States Michelle Hoeger Roger Gibbs Signed (1) The corporation rejects the employers’ liability coverage. Chuck Amling mitzi@bruggemanlumber.com Self Garber Clayton United States Michelle Hoeger Roger Gibbs Signed
874 2024-01-29 14:30 Anonymous (not verified) 94.188.205.174 Proefco LLC 502 s Cadwell 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. 2024-01-30 Kendy Melendrez kendydej@gmail.com Eagle Grove IA IA Kendy Melendrez Jaime Hernandez Signed (2) The corporation declines to reject the employers’ liability coverage. Kendy Melendrez kendydej@gmail.com owner Eagle Grove IA IA Kendy Melendrez Jaime Hernandez Signed
897 2024-02-24 18:40 Anonymous (not verified) 94.188.205.169 Rays Plumbing Heating & Air conditioning LLC. 305 Cedar St. Tipton Iowa 52772 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-02-24 Raymond Zaruba raymondzaruba@gmail.com TIPTON IA United States Kevin Kofron Jodi Kofron Signed (1) The corporation rejects the employers’ liability coverage. Raymond Zaruba raymondzaruba@gmail.com Owner Tipton Iowa 52772 Cedar Iowa Kevin Kofron Jodi Kofron Signed
898 2024-02-24 21:06 Anonymous (not verified) 94.188.207.226 Under Pressure Pressure on 1008 Doubletree Ct NE I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-24 Kevin M Feeney kevin.feeney45@gmail.com Cedar Rapids IA United States Taryn Erbes Susan Erbes Signed (1) The corporation rejects the employers’ liability coverage. Kevin M Feeney kevin.feeney45@gmail.com Owner Cedar Rapids IA United States Taryn Erbes Susan Erbes Signed
903 2024-02-27 13:54 Anonymous (not verified) 94.188.205.166 MELTZ'S CONSTRUCTION LLC 402 Jennifer Ln NE Cedar Rapids IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-27 RICARDO MELTZ waymakeranasolorzano@gmail.com CADAR RAPIDS IA United States Lysandra Betancourt Belkis S Diaz Signed (1) The corporation rejects the employers’ liability coverage. ALAN SALGADO alan@prime-agents.com OWNER IRVING TX United States Lysandra Betancourt Belkis S Diaz Signed
920 2024-03-18 15:42 Anonymous (not verified) 94.188.207.223 Great Tree LLC 2701 e douglas ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-18 Robert buell Greattree55@gmail.com Des Moines IA United States ryan homan Jamarlo fields Signed (1) The corporation rejects the employers’ liability coverage. Robert buell Greattree55@gmail.com company owner Des Moines IA United States ryan homan jamarlo fields Signed
921 2024-03-18 15:45 Anonymous (not verified) 94.188.207.226 Great Tree LLC 2701 e douglas ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-18 Timothy Buell treeshark52@gmail.com Des Moines IA United States ryan homan Jamarlo fields Signed (1) The corporation rejects the employers’ liability coverage. Robert buell Greattree55@gmail.com company owner Des Moines IA United States ryan homan jamarlo fields Signed
926 2024-03-20 15:25 Anonymous (not verified) 94.188.207.230 CML Constuction LLC 2116 Park Ave Muscatine, Iowa 52761 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-20 CHRIS LINNENKAMP cmlconstructionllc@gmail.com Muscatine IA IA Gabriel Diaz Byron Lopez Signed (1) The corporation rejects the employers’ liability coverage. CHRIS LINNENKAMP cmlconstructionllc@gmail.com Owner Muscatine IA IA Gabriel Diaz Byron Lopez Signed
927 2024-03-20 23:27 Anonymous (not verified) 94.188.205.177 RRB, LLC 4444 1st Ave NE Ste 510 Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-20 Kelli Holton kelli@rebelroseboutique.co Coralville IA United States Dave Booth Ann Holton Signed (1) The corporation rejects the employers’ liability coverage. Kelli Holton kelli@rebelroseboutique.co Owner Coralville IA United States Dave Booth Ann Holton Signed
943 2024-04-03 12:07 Anonymous (not verified) 94.188.205.166 Invisible Fence of NCI, Inc 408 5th St, Ste 100 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-04 Paul Andy Timm ifbcentraliowa@yahoo.com Madrid IA Iowa Lisa Timm Kari Rigby Signed (1) The corporation rejects the employers’ liability coverage. Lisa Busch Timm centraliowa@invisiblefence.com Spouse Madrid IA United States Lisa Timm Kari Rigby Signed
945 2024-04-03 20:00 Anonymous (not verified) 94.188.207.229 Timberview Construction 803 TIMBERVIEW 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. (1) I reject the employers’ liability coverage. 2024-04-03 Parker Evans Pcevans28@gmail.com ADEL IA United States jason Evans Tricia Evans Signed (1) The corporation rejects the employers’ liability coverage. Timberview Construction Pcevans28@gmail.com Myself ADEL IA United States Jason Evans Tricia Evans Signed
961 2024-04-25 13:08 Anonymous (not verified) 94.188.207.227 PROEFCO LLC 502 South Cadwell Avenue I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-25 Kendy Melendrez Figueroa Kendydej@gmail.com Eagle Grove IA United States Kendy M Figueroa Kendy M Figueroa Signed (1) The corporation rejects the employers’ liability coverage. Kendy M Figueroa Kendydej@gmail.com Owner Eagle Grove IA United States Kendy M Figueroa Kendy M Figueroa Signed
971 2024-05-03 07:33 Anonymous (not verified) 94.188.205.176 Outdoor Pros LLC 6535 WAPSI AVE SE Lone Tree IA 52755 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-02 Erik Alberhasky erikalberhas@gmail.com LONE TREE IA United States Melanie Hockenson Robin Morrison Signed (1) The corporation rejects the employers’ liability coverage. Erik Alberhasky erikalberhas@gmail.com Owner LONE TREE IA United States Melanie Hockenson Robin Morrison Signed
972 2024-05-03 07:35 Anonymous (not verified) 94.188.205.175 Outdoor Pros LLC 6535 WAPSI AVE SE Lone Tree IA 52755 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-02 Erik Alberhasky erikalberhas@gmail.com LONE TREE IA United States Melanie Hockenson Robin Morrison Signed (1) The corporation rejects the employers’ liability coverage. Erik Alberhasky erikalberhas@gmail.com Owner LONE TREE IA United States Melanie Hockenson Robin Morrison Signed
974 2024-05-06 08:02 Anonymous (not verified) 94.188.205.176 Milton Recycling & Roll Off Service LLC 1266 218 PL, Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-06 Glenn Kreuder kreuderfarms@yahoo.com Boone IA United States Amanda Krull Adam Krull Signed (1) The corporation rejects the employers’ liability coverage. Glenn Kreuder kreuderfarms@yahoo.com Member Boone IA United States Amanda Krull Adam Krull Signed
123 2020-10-20 17:35 Anonymous (not verified) 66.172.250.9 Ladwig Constrution 509 Moorehead St. Ida Grove, IA 51445 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. 2020-10-20 Ross Ladwig rossladwig@gmail.com Ida Grove Ida Iowa Christine Ladwig Kya Ladwig Signed (2) The corporation declines to reject the employers’ liability coverage. Ross Ladwig rossladwig@gmail.com Owner Ida Grove Ida Iowa Christine Ladwig Kya Ladwig Signed
227 2021-04-02 09:58 Anonymous (not verified) 207.177.7.191 GOETTSCH DISPATCH INC 200 MAIN ST GALVA, IA 51020 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. 2021-03-15 ANDREW GOETTSCH andygoettsch@gmail.com Galva Ida Iowa Kristy Dewey Terri Ullrich Signed (1) The corporation rejects the employers’ liability coverage. Andrew Goettsch andygoettsch@gmail.com President Galva Ida Iowa Kristy Dewey Terri Ullrich Signed
845 2024-01-02 09:03 Anonymous (not verified) 94.188.205.169 American Tree Service LLC 416 S Kiel Street, Holstein, IA 51025 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. 2024-01-02 Austin Thevenot americantreeservice03@gmail.com Holstein Ida Iowa Jared Brashears Katie Gunkelman Signed (1) The corporation rejects the employers’ liability coverage. Austin Thevenot americantreeservice03@gmail.com Owner Holstein Ida Iowa Jared Brashears Katie Gunkelman Signed
982 2024-05-10 19:06 Anonymous (not verified) 94.188.207.228 Revella Salon and Spa 509 Second St Ida Grove, IA 51445 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-10 Bailey Roeder roeder428@gmail.com Ida Grove Ida Iowa Dalton Hemer Fina Roeder Signed (1) The corporation rejects the employers’ liability coverage. Bailey Roeder roeder428@gmail.com Myself Ida Grove Ida Iowa Dalton Hemer Fina Roeder Signed
808 2023-11-08 07:37 Anonymous (not verified) 94.188.207.229 Cush Comfort 1225 e. River Dr STE 206 Davenport IA 52803 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. 2023-10-30 Chris Cushman ccushman82@gmail.com Milan IL United States Deena Maurus Jenna Ortberg Signed (1) The corporation rejects the employers’ liability coverage. Christopher Cushman ccushman82@gmail.com Owner Milan IL United States Deena Maurus Jenna Ortberg Signed
189 2021-02-25 10:56 Anonymous (not verified) 173.27.130.150 Southside Boat Club Post Office Box 674, Keokuk, Iowa 52632 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. 2021-02-01 Kathryn L. Farris southsideboatclub@gmail.com Hamilton Illinois United States Roger D. Huston Janis Leann Wallingford Signed (1) The corporation rejects the employers’ liability coverage. Jeri Denise Asbridge Kerryasbridge1@mediacombb.net Treasurer Hamilton Illinois United States Roger D. Huston Janis Leann Wallingford Signed
190 2021-02-25 10:57 Anonymous (not verified) 173.27.130.150 Southside Boat Club Post Office Box 674, Keokuk, Iowa 52632 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. 2021-02-01 Kathryn L. Farris southsideboatclub@gmail.com Hamilton Illinois United States Roger D. Huston Janis Leann Wallingford Signed (1) The corporation rejects the employers’ liability coverage. Jeri Denise Asbridge Kerryasbridge1@mediacombb.net Treasurer Hamilton Illinois United States Roger D. Huston Janis Leann Wallingford Signed
192 2021-02-25 11:10 Anonymous (not verified) 173.27.130.150 Southside Boat Club Post Office Box 674, Keokuk, Iowa 52632 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. 2021-02-01 Jeri Asbridge kerryasbridge1@mediacombb.net Hamilton Illinois United States Roger D. Huston Janis Leann Wallingford Signed (1) The corporation rejects the employers’ liability coverage. Jeri Asbridge Kerryasbridge1@mediacombb.net Treasurer Hamilton Illinois United States Roger D. Huston Janis Leann Wallingford Signed
33 2020-01-15 10:31 Anonymous (not verified) 216.161.118.103 ELOHIM HOME CARE AND STAFFING AGENCY, INC 301 NE Trilein Dr , ste 4B, Ankeny IA 50021 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-01-15 NITEZEHO NIYOMUGABO john@elohimhcs.com Ankeny Iowa United States john Tez Sem R Signed (1) The corporation rejects the employers’ liability coverage. John Tez john@elohimhcs.com Director Ankeny IA United States John Tez Tez Signed
54 2020-04-03 19:30 Anonymous (not verified) 173.25.134.162 Luke Laxton 1502 guthrie 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. 2020-04-03 Luke Laxton kyekingstonl@gmail.com Des Moines Iowa United States Omer Okic Nicholas weber Signed (1) The corporation rejects the employers’ liability coverage. Luke Laxton kyekingstonl@gmail.com Owner Des Moines Iowa United States Omer Okic Nicholas weber Signed
92 2020-06-30 13:46 Anonymous (not verified) 50.82.87.122 Diamond Bath LLC 3184 Berkshire Pkwy Clive, Iowa 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-01-01 Patricia Fisk diamondbathllc@gmail.com Clive Iowa United States Josh Fisk Tom Childes Signed (1) The corporation rejects the employers’ liability coverage. Patricia Fisk diamondbathllc@gmail.com Owner/CEO Clive Iowa United States Josh Fisk Tom Childes Signed
93 2020-06-30 13:48 Anonymous (not verified) 50.82.87.122 Waterfall Design LLC 3184 Berkshire Pkwy Clive, Iowa 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-01-01 John Lanscak III waterfalldesign3@gmail.com Clive Iowa United States Josh Fisk Tom Childes Signed (1) The corporation rejects the employers’ liability coverage. John Lanscak III waterfalldesign3@gmail.com owner/CEO Clive Iowa United States Josh Fisk Tom Childes Signed
147 2020-12-29 13:57 Anonymous (not verified) 208.38.231.99 CJ Construction 2129N Zenith 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. 2020-12-29 Christine Ekin John Ekin chrohn2009@yahoo.com Davenport Iowa United States Christine Ekin John J Ekin Signed (1) The corporation rejects the employers’ liability coverage. CJ Construction chrohn2009@yahoo.com Co Owner Davenport Iowa United States Christine Ekin John J Ekin Signed
172 2021-01-26 19:02 Anonymous (not verified) 173.17.8.56 Hutch's Parking Lot Sweeping 5235 JENNIFER 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. (1) I reject the employers’ liability coverage. 2021-01-26 Bill HUTCHINSON btnwhutch@aol.com PLEASANT HILL Iowa United States TRACY HUTCHINSON WHITNIE HUTCHINSON Signed (1) The corporation rejects the employers’ liability coverage. Bill HUTCHINSON btnwhutch@aol.com Self PLEASANT HILL Iowa United States TRACY HUTCHINSON WHITNIE HUTCHINSON Signed
184 2021-02-20 15:18 Anonymous (not verified) 75.162.213.162 MJM, INC. 32345 - 200TH ST., DALLAS CENTER, IA 50063 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. 2021-02-20 MICHAEL CONNOLLY MJMINC2000@AOL.COM Dallas Center Iowa United States Stephen L. Davis Jackson Plagge Signed (1) The corporation rejects the employers’ liability coverage. MICHAEL CONNOLLY MJMINC2000@AOL.COM Vice President Dallas Center Iowa United States Stephen L. Davis Jackson Plagge Signed
269 2021-05-25 20:25 Anonymous (not verified) 174.71.12.114 The Town and Country Aqua Club of Council Bluffs 15444 Cherry Tree Lane Council Bluffs, Iowa 51503 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. 2021-05-25 David Alan Bergman dbrgmn@gmail.com Council Bluffs Iowa United States Brett Ford Sean Dunphy Signed (1) The corporation rejects the employers’ liability coverage. David Alan Bergman dbrgmn@gmail.com Board Vice President Council Bluffs Iowa United States Brett Ford Sean Dunphy Signed
277 2021-06-17 21:34 Anonymous (not verified) 97.125.98.166 J. Bos Holdings 10925 NE 23rd Ave Mitchellville, IA 50169 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. 2021-06-17 Jeff Bos jeffbos1967@gmail.com Mitchellville Iowa United States Angela Bos Amy Bos Signed (1) The corporation rejects the employers’ liability coverage. Jeff Bos jeffbos1967@gmail.com officer Mitchellville Iowa United States Angela Bos Amy Bos Signed
321 2021-08-27 16:10 Anonymous (not verified) 173.30.51.29 Diamond Bath LLC 3184 Berkshire PKwy Clive, Iowa 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-02 Patricia Fisk diamondbathllc@gmail.com Clive Iowa United States Joshua A Fisk John S Lanscak III Signed (1) The corporation rejects the employers’ liability coverage. Patricia Fisk diamondbathllc@gmail.com Owner/CEO Clive Iowa United States Joshua A Fisk John S Lanscak III Signed
337 2021-09-16 21:28 Anonymous (not verified) 173.17.8.56 Hutch's Parking Lot Sweeping Inc. 5235 Jennifer 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. (1) I reject the employers’ liability coverage. 2021-09-16 Bill E Hutchinson btnwhutch@aol.com Pleasant Hill Iowa Iowa Tracy Hutchinson Nic Hutchinson Signed (1) The corporation rejects the employers’ liability coverage. Bill E Hutchinson btnwhutch@aol.com Same Pleasant Hill Iowa Iowa Tracy Hutchinson Nic Hutchinson Signed
378 2022-01-03 15:16 Anonymous (not verified) 217.180.230.157 True360, Inc. 1805 Collaboration Place, Suite 1300, Ames, Iowa 50010 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. 2022-01-03 Christopher James chris@true-360.com Ames Iowa United States Jesse Kisker Cody Kapka Signed (1) The corporation rejects the employers’ liability coverage. Christopher James chris@true-360.com President and Chief Executive Officer Ames Iowa United States Jesse Kisker Cody Kapka Signed
405 2022-02-14 10:36 Anonymous (not verified) 207.199.239.234 My Nest Greenhouse 1134-1600 St I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-14 Patti Bogler mynest@fmctc.com Harlan Iowa Iowa Hallie Carroll Katrina Shea Signed (1) The corporation rejects the employers’ liability coverage. Patti Bogler mynest@fmctc.com owner Harlan Iowa Iowa Hallie Lynn Carroll Katrina Mae Shea Signed
423 2022-03-08 12:17 Anonymous (not verified) 173.18.193.171 BARNES INC 1214 40TH ST FORT MADISON IA 52627 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. 2021-03-08 dwight barnes humburdautoservice455@gmail.com Fort Madison Iowa United States Tyson P Barnes Brandon L Barnes Signed (1) The corporation rejects the employers’ liability coverage. dwight barnes humburdautoservice455@gmail.com President Fort Madison Iowa United States Tyson P Barnes Brandon L Barnes Signed
441 2022-04-11 13:15 Anonymous (not verified) 75.162.175.12 Castro construction LLC 1712 carpenter av desmoines Iowa 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-11 Carlos Alberto castro Alcántara castrodvxhd@gmail.com Estados Unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe padilla bonilla Signed (1) The corporation rejects the employers’ liability coverage. Carlos Alberto castro Alcántara castrodvxhd@gmail.com Owner Estados unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe Padilla Bonilla Signed
442 2022-04-11 13:15 Anonymous (not verified) 75.162.175.12 Castro construction LLC 1712 carpenter av desmoines Iowa 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-11 Carlos Alberto castro Alcántara castrodvxhd@gmail.com Estados Unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe padilla bonilla Signed (1) The corporation rejects the employers’ liability coverage. Carlos Alberto castro Alcántara castrodvxhd@gmail.com Owner Estados unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe Padilla Bonilla Signed
443 2022-04-11 13:15 Anonymous (not verified) 75.162.175.12 Castro construction LLC 1712 carpenter av desmoines Iowa 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-11 Carlos Alberto castro Alcántara castrodvxhd@gmail.com Estados Unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe padilla bonilla Signed (1) The corporation rejects the employers’ liability coverage. Carlos Alberto castro Alcántara castrodvxhd@gmail.com Owner Estados unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe Padilla Bonilla Signed
461 2022-05-02 11:08 Anonymous (not verified) 192.119.212.86 Iceberg Enterprises LLC 101 E. 1st street Arthur IA 51431 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-02 Jesse Bergman jk_montana@yahoo.com arthur Iowa United States Maren Smith Darren Smith Signed (1) The corporation rejects the employers’ liability coverage. Katherine Bergman jk_montana@yahoo.com Owner Arthur IOWA United States Susan Bergman Jesse Bergman Signed
492 2022-06-06 20:18 Anonymous (not verified) 69.54.109.51 R C TRUCKING, LTD. 16125 310th Street, Mason City, Iowa 50401 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-06 ROGER CHIZEK joldoak@gmail.com MASON CITY Iowa United States Kathy Zobrist Alan Zobrist Signed (1) The corporation rejects the employers’ liability coverage. ROGER CHIZEK joldoak@gmail.com President MASON CITY Iowa United States Kathy Zobrist Alan Zobrist Signed
561 2022-11-03 11:24 Anonymous (not verified) 96.31.21.117 Northwest 9 Inc. 1512 Elmwood Ave. I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-03 Ethan Meyer ethanmeyer83@gmail.com ROCK RAPIDS Iowa United States Brad Meyer Trinda Meyer Signed (1) The corporation rejects the employers’ liability coverage. Brad Meyer nw9farm@gmail.com owner Rock Rapids IA United States Trinda Meyer Brad Meyer Signed
592 2023-01-22 11:29 Anonymous (not verified) 216.106.211.176 Trackside Service & Repair Inc. 205 Main St. Alvord, IA 51230 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. 2022-01-22 Renee J Klarenbeek dkranch@alliancecom.net Rock Rapids Iowa United States Steve C. Green Darwyn G. Klarenbeek Signed (1) The corporation rejects the employers’ liability coverage. Darwyn G. Klarenbeek trackside@alliancecom.net Owner Rock Rapids Lyon IA Steve C. Green Darwyn G. Klarenbeek Signed
595 2023-01-31 09:35 Anonymous (not verified) 50.83.168.191 Lumos Electric, Inc DBA Dave Bessine Electric 705 Valley Street, Burlington, Iowa, 52601 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-31 Shawna Brown recdbessine@qwestoffice.net Burlington iowa United States Shelly Knight DeeAnn Howard Signed (1) The corporation rejects the employers’ liability coverage. Tim Brown recdbessine@qwestoffice.net Vice-President Burlington iowa United States Shelly Knight DeeAnn Howard Signed
619 2023-03-06 09:02 Anonymous (not verified) 94.188.207.229 Gaytan Framing LLC 4745 NE 27th Ct Des Moines IA 50317 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-06 Jose Gaytan jose1988.jg8@gmail.com Des Moines Iowa United States Carla Gaytan Eduardo Vazquez Signed (1) The corporation rejects the employers’ liability coverage. Jose Gaytan jose1988.jg8@gmail.com Owner Des Moines Polk IA Carla Gaytan Eduardo Vazquez Signed