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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:
652 2023-04-17 16:23 Anonymous (not verified) 94.188.205.177 alternative sport enterprises llc 506 6th st coralville IA 52241 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. 2023-04-17 nick carroll nick.carroll@mchsi.com Coralville IA United States Kaylyn Olson Jake Braman Signed (1) The corporation rejects the employers’ liability coverage. nick carroll nick.carroll@mchsi.com owner Coralville IA United States Kaylyn Olson Jake Braman Signed
653 2023-04-17 16:37 Anonymous (not verified) 94.188.205.166 alternative sport enterprises llc 506 6th 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. 2023-04-17 James Pearson jimpearson444@yahoo.com Savage scott MN Kaylyn Olson Jake Braman Signed (1) The corporation rejects the employers’ liability coverage. nick carroll nick.carroll@mchsi.com Owner Coralville IA United States Kaylyn Olson Jake Braman Signed
822 2023-11-20 09:43 Anonymous (not verified) 94.188.207.223 Lifeson LLC 303 6th Ave Coralville IA 52241 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-14 Scott Parshall scott@lifeson.com Coralville Johnson Iowa Samantha Mlavsky Pamela Mahon Signed (1) The corporation rejects the employers’ liability coverage. Scott Parshall scott@lifeson.com member Coralville Johnson Iowa Samantha Mlavsky Pamela Mahon 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
933 2024-03-22 21:55 Anonymous (not verified) 94.188.205.176 Alternative Sport Enterprises 101 Highway 1 West 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. 2024-03-22 James Michael Pearson hatchetjacksiowa@gmail.com Savage Scott County Minnesota Payton Kahl Trey Kahl Signed (1) The corporation rejects the employers’ liability coverage. Nick John Carroll hatchetjacksiowa@gmail.com Owner CORALVILLE Johnson County Iowa Payton Kahl Trey Kahl Signed
977 2024-05-08 11:12 Anonymous (not verified) 94.188.207.230 JPZ Logistics LLC 945 Elm St, Naperville, IL 60540 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. 2024-05-08 John Loren Polk II jpolk@polksolutions.com Coralville Johnson Iowa Nicholas Dedio Ric Mills Signed (1) The corporation rejects the employers’ liability coverage. John Loren Polk jpolk@polksolutions.com owner Coralville Iowa United States Ric Mills Nicholas Dedio Signed
825 2023-11-22 08:02 Anonymous (not verified) 94.188.207.224 Sabuydee Corporation 617 Davis Ave. / Corning, IA 50841 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. 2023-11-22 Nantawan Grundman lakejournal@gmail.com Corning Adams Iowa Carol Penglase Michael Grundman Signed (1) The corporation rejects the employers’ liability coverage. Adam Grundman adamgrundman@gmail.com President Corning Iowa United States Carol Penglase Michael Grundman Signed
826 2023-11-22 08:04 Anonymous (not verified) 94.188.207.226 Sabuydee Corporation 617 Davis Ave. / Corning, IA 50841 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. 2023-11-22 Adam Grundman adamgrundman@gmail.com Corning Adams Iowa Carol Penglase MIchael Grundman Signed (1) The corporation rejects the employers’ liability coverage. Adam Grundman adamgrundman@gmail.com President Corning Iowa United States Carol Penglase Michael Grundman Signed
174 2021-01-29 12:08 Anonymous (not verified) 108.174.118.195 Tempered Solutions HVAC LLC 897 Old Corvallis Road I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-29 Zachery Wiediger temperedsolutionshvac@gmail.com Corvallis Montana United States Julie R. Ostrenga Douglas M. Ostrenga Signed (1) The corporation rejects the employers’ liability coverage. Zachery Wiediger temperedsolutionshvac@gmail.com Self Corvallis Montana United States Douglas M. Ostrenga Julie R. Ostrenga Signed
253 2021-05-04 16:17 Anonymous (not verified) 207.32.14.70 Experts Roofing LLC 8655 81st St S, Cottage Grove MN 55016 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-04 Victor Oropeza vikrosales@hotmail.com Cottage Grove Washington MN Emily Danner Michael Karels Signed (1) The corporation rejects the employers’ liability coverage. Victor Oropeza vikrosales@hotmail.com Owner Cottage Grove Washington MN Emily Danner Michael Karels Signed
258 2021-05-06 10:57 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 Woltemath rwoltem@gmail.com HAMBURG IA United States 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
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
264 2021-05-18 22:36 Anonymous (not verified) 174.71.14.68 Town and country Aqua Club 22687 James 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. 2021-05-18 Hope LaShea Diercks townandcountrycb@gmail.com Council bluffs Pottawattamie Iowa John James Diercks Keenan James Diercks Signed (1) The corporation rejects the employers’ liability coverage. Hope LaShea Diercks townandcountrycb@gmail.com Treasurer Council bluffs Pottawattamie Iowa John James Diercks Keenan James Diercks Signed
267 2021-05-24 11:25 Anonymous (not verified) 70.168.33.178 Town and Country Aqua Club 22687 James Dr, council bluffs, IA 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. 2021-05-24 Cheri Smith 3smithathome@cox.net Council Bluffs Pottawattamie IA Mark Smith Kirstyn Smith Signed (1) The corporation rejects the employers’ liability coverage. Cheri Smith 3smithathome@cox.net Secretary Council Bluffs Pottawattamie IA Mark Smith Kirstyn Smith 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
379 2022-01-04 14:10 Anonymous (not verified) 97.107.199.129 Premier Show Productions 1304 Skyline Dr Council Bluffs IA I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-20 Scott Brandenburg scottsuperiorservices@gmail.com Council Bluffs POtt Iowa Jan andersen Brad Andersen Signed (1) The corporation rejects the employers’ liability coverage. Scott Brandenburg scottsuperiorservices@gmail.com self Council Bluffs Pott Iowa Jan Andersen Brad Andersen Signed
565 2022-11-14 08:22 Anonymous (not verified) 97.119.175.158 CenterLine Electric Inc 22004 185th St Council Bluffs IA I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-14 Jonathon w Haldeman centerline.electric@yahoo.com council bluffs pottawattamie Iowa cathy haldeman koleen haldeman Signed (1) The corporation rejects the employers’ liability coverage. jonathon haldeman centerline.electric@yahoo.com owner council bluffs pottawattamie iowa cathy haldeman koleen haldeman Signed
627 2023-03-17 06:48 Anonymous (not verified) 94.188.207.229 Hearing Health Care, LLC 2519 South 16th Street Council Bluffs, IA 51501 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. 2023-03-17 Melissa Ann Knoell melissaknoell@yahoo.com Council Bluffs Pottowattomi Iowa Bruce Carol Johnk Marcelyn Maureen Johnk Signed (1) The corporation rejects the employers’ liability coverage. Melissa Ann Knoell melissaknoell@yahoo.com Self Council Bluffs Pottawattomi Iowa Bruce Carol Johnk Marcelyn Maureen Johnk Signed
875 2024-01-30 14:18 Anonymous (not verified) 94.188.207.226 Central Athletics LLC 7 S 4th Street 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. 2024-01-30 Cait Boyer centralathleticsia@gmail.com Council Bluffs Pottawattamie Iowa Justice Woolard Erin Eby Signed (1) The corporation rejects the employers’ liability coverage. Cait Boyer centralathleticsia@gmail.com President Council Bluffs Pottawattamie Iowa Justice Woolard Erin Eby Signed
980 2024-05-10 14:51 Anonymous (not verified) 94.188.205.176 Access Door Automation 19068 Mynster Springs Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-10 Marshall Miller millermarshallt@outlook.com council bluffs Iowa United States Kylee Miller Ivy Miller Signed (1) The corporation rejects the employers’ liability coverage. Marshall Miller millermarshallt@outlook.com owner council bluffs Iowa United States Kylee Miller Ivy Miller Signed
18 2019-12-16 14:00 Anonymous (not verified) 206.80.132.15 Cresco Family Dentistry P.C. 210 N Elm St Cresco, IA 52136 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-12-16 Jeffrey K Haw cfdentistry@iowatelecom.net Cresco Howard Iowa Don Dietzenbach Kim Holmes Signed (1) The corporation rejects the employers’ liability coverage. Jeffrey K Haw cfdentistry@iowatelecom.net President Cresco Howard Iowa Don Dietzenbach Kim Holmes Signed
19 2019-12-16 14:04 Anonymous (not verified) 206.80.132.15 Cresco Family Dentistry P.C. 210 N Elm St Cresco, IA 52136 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-12-16 Shirlee J Haw cfdentistry@iowatelecom.net Cresco Howard Iowa Don Dietzenbach Kim Holmes Signed (1) The corporation rejects the employers’ liability coverage. Jeffrey K Haw cfdentistry@iowatelecom.net President Cresco Howard Iowa Don Dietzenbach Kim Holmes Signed
760 2023-09-01 08:43 Anonymous (not verified) 94.188.207.226 Paradigm Group, LLC 3263 Cumming Road, Cumming, IA 50061 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. 2023-09-01 Conor Davis conor@cdavisflooring.com Urbandale Dallas Iowa Jered Holker Wes Duncan Signed (1) The corporation rejects the employers’ liability coverage. Ryan Shabino ryan@prdgmgroup.com Owner Cumming Madison Iowa Wes Duncan Jered Holker Signed
761 2023-09-01 08:52 Anonymous (not verified) 94.188.205.177 Paradigm Group, LLC 3263 Cumming Road, Cumming, IA 50061 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. 2023-09-01 Rony De Leon ronydeleon22@icloud.com Des Moines Polk Iowa Jered Holker Wes Duncan Signed (1) The corporation rejects the employers’ liability coverage. Ryan Shabino ryan@prdgmgroup.com Owner Cumming Madison Iowa Wes Duncan Jered Holker Signed
762 2023-09-01 09:00 Anonymous (not verified) 94.188.207.226 Paradigm Group, LLC 3263 Cumming Road, Cumming, IA 50061 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. 2023-09-01 Hunter Fees iowatuckpointing@gmail.com Carlisle Warren Iowa Jered Holker Wes Duncan Signed (1) The corporation rejects the employers’ liability coverage. Ryan Shabino ryan@prdgmgroup.com Owner Cumming Madison Iowa Wes Duncan Jered Holker Signed
887 2024-02-08 13:40 Anonymous (not verified) 94.188.207.228 Paradigm Construction 3263 Cumming Rd. Cumming, IA 50061 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. 2024-02-08 Justin Huss jmanhuss@gmail.com Grimes Polk Iowa Katie Hennessey Ryan Shabino Signed (1) The corporation rejects the employers’ liability coverage. Ryan Shabino office@prdgmgroup.com Owner Cumming Warren Iowa Katie Hennessey Nicole Shabino Signed
979 2024-05-10 14:40 Anonymous (not verified) 94.188.207.224 Paradigm Group, LLC 3263 Cumming Road, Cumming IA. 50061 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 Hunter Brown bbpropertymaintenance1@gmail.com Ankeny Polk County Iowa Landon Brown Ryan Rose Signed (1) The corporation rejects the employers’ liability coverage. Kelsey Prince office@prdgmgroup.com Office Manager Cumming Madison Iowa Kyle McGinn Robin McGinn Signed
451 2022-04-22 16:06 Anonymous (not verified) 75.63.172.134 Tempus Builders, Inc. 4331 Valley Ridge Rd. I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-22 Scott Cooper scott@tempusbuilders.com Dallas TX United States Phil Sheumaker Cristen Cooper Signed (1) The corporation rejects the employers’ liability coverage. Scott Cooper scott@tempusbuilders.com President Dallas TX United States James Buckley Phil Sheumaker Signed
452 2022-04-22 16:06 Anonymous (not verified) 75.63.172.134 Tempus Builders, Inc. 4331 Valley Ridge Rd. I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-22 Scott Cooper scott@tempusbuilders.com Dallas TX United States Phil Sheumaker Cristen Cooper Signed (1) The corporation rejects the employers’ liability coverage. Scott Cooper scott@tempusbuilders.com President Dallas TX United States James Buckley Phil Sheumaker Signed
453 2022-04-22 16:07 Anonymous (not verified) 75.63.172.134 Tempus Builders, Inc. 4331 Valley Ridge Rd. I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-22 Jennifer Cooper scott@tempusbuilders.com Dallas TX United States Phil Sheumaker Cristen Cooper Signed (1) The corporation rejects the employers’ liability coverage. Scott Cooper scott@tempusbuilders.com President Dallas TX United States James Buckley Phil Sheumaker 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
282 2021-06-30 12:31 Anonymous (not verified) 204.155.61.217 Stout Roofing Inc 1200 Ash 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. 2021-06-30 Jacob Stout jacobstout@hailmayday.com Dallas Center Dallas County IA Ashley Kraft Docusign Signed (1) The corporation rejects the employers’ liability coverage. Jacob Stout jacobstout@hailmayday.com Owner Dallas center Dallas IA Ashley Kraft Docusign Signed
447 2022-04-15 16:59 Anonymous (not verified) 166.181.87.86 STEVE MORRISON TRUCKING P.O. Box 66 Danville,IA 52623 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. 2022-04-15 Stephen D. Morrison sdmt13@gmail.com Danville Des Moines IA Ellie Miller Janice Helt Signed (1) The corporation rejects the employers’ liability coverage. Stephen Dwight Morrison sdmt13@gmail.com Owner Danville Des Moines IA Ellie Miller Janice Helt Signed
17 2019-12-12 13:20 Anonymous (not verified) 65.126.161.162 Robert J Schroeder Const. Inc. 10984 150th St Davenport, IA 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-12-12 Robert J Schroeder None@none.com Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed (1) The corporation rejects the employers’ liability coverage. Robert J Schroeder None@none.com President Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed
47 2020-03-10 15:16 Anonymous (not verified) 65.126.161.162 Advantage Customer Remodeling LLC 3236 W 17th Street Davenport, IA 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-10 Tamethia Mitchell None@none.com Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed (1) The corporation rejects the employers’ liability coverage. Tamethia Mitchell None@none.com Owner Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed
69 2020-04-21 10:18 Anonymous (not verified) 65.126.161.162 Mike Foster DBA Mike's Home Improvement 2377 W 49th Street Davenport, IA 52806 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. 2020-04-21 Michael A Foster Jr. None@none.com Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed (1) The corporation rejects the employers’ liability coverage. Michael A Foster Jr. None@none.com Owner Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed
114 2020-09-04 13:11 Anonymous (not verified) 107.182.207.0 KEITH N SLYTER PO 2632 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-04 KEITH N SLYTER KNSCONST@GMAIL.COM DAVENPORT 25|IA iowa KEITH N SLYTER KEITH N SLYTER Signed (1) The corporation rejects the employers’ liability coverage. KEITH N SLYTER KNSCONST@GMAIL.COM owner DAVENPORT 25|IA iowa KEITH N SLYTER KEITH N SLYTER 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
173 2021-01-26 19:29 Anonymous (not verified) 173.17.84.174 Robert Schroeder const. inc 10984 150 th. st. davenport ia. 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-26 ROBERT SCHROEDER r.schroeder@aol.com davenport scott ia. Debra Blaser John Ekin Signed (1) The corporation rejects the employers’ liability coverage. ROBERT SCHROEDER r.schroeder@aol.com President davenport scott ia. Debra Blaser John Ekin Signed
185 2021-02-23 15:16 Anonymous (not verified) 173.29.151.168 TONY V'S PAINTING 2316 CRESCENT AVE DAVENPORT, IA 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-23 ANTHONY VANCE ANTHONYJV1977@GMAIL.COM DAVENPORT SCOTT IA TONY BURKHART RICHARD MILLER-VANCE Signed (1) The corporation rejects the employers’ liability coverage. ANTHONY VANCE ANTHONYJV1977@GMAIL.COM OWNER DAVENPORT SCOTT IA TONY BURKHART RICHARD MILLER-VANCE Signed
193 2021-03-02 11:32 Anonymous (not verified) 50.83.72.164 4 corners drywall 532 w 15 st, Davenport, iowa 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. (2) I decline to reject the employer’s liability coverage. 2021-03-02 Phillip hoxsey Phillhoxsey81@gmail.com Davenport Scott Iowa Donivan hoxsey Connor ruge Signed (2) The corporation declines to reject the employers’ liability coverage. Phillip hoxsey Phillhoxsey81@gmail.com Owner Davenport Scott Iowa Donivan hoxsey Connor ruge Signed
194 2021-03-02 11:42 Anonymous (not verified) 50.83.72.164 D’s Drywall 1217 n Blanchard 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. (2) I decline to reject the employer’s liability coverage. 2021-03-02 Donivan hoxsey hdonivan@gmail.com Davenport Scott Iowa Phillip hoxsey Connor ruge Signed (2) The corporation declines to reject the employers’ liability coverage. Donivan hoxsey hdonivan@gmail.com Owner Davenport Scott Iowa Phillip hoxsey Connor ruge Signed
195 2021-03-02 16:29 Anonymous (not verified) 173.29.156.163 Certified drywall 329 e.11th st Davenport, Iowa 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. 2021-03-02 Thomas wells mikeparry783@gmail.com Davenport Scott Iowa Chyna rose pena Natalie parry Signed (2) The corporation declines to reject the employers’ liability coverage. Thomas wells mikeparry783@gmail.com Self Davenport Scott Iowa Chyna rose pena Natalie parry Signed
198 2021-03-03 17:14 Anonymous (not verified) 173.29.156.163 Jdw 329 E. 11th st davenport 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. 2021-03-03 James holzer slickninja00@gmail.com Davenport Scott Iowa Alyssa holzer Kory munn Signed (2) The corporation declines to reject the employers’ liability coverage. James holzer slickninja00@gmail.com Myself Davenport Scott Iowa Alyssa holzer Kory munn Signed
199 2021-03-03 17:32 Anonymous (not verified) 172.58.86.222 Mike Underdahl 1536 W Locust St I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-03 Mike Underdahl mwunderdahl1974@gmail.com Davenport Scott Iowa Phillip Gerald Hoxsey Amee Ann Pepperson Signed (1) The corporation rejects the employers’ liability coverage. Michael Wayne Underdahl mwunderdahl1974@gmail.com Self Davenport Scott Iowa Phillip Gerald Hoxsey Amme Ann Pepperson Signed
200 2021-03-03 17:33 Anonymous (not verified) 172.58.84.30 Amee Ann Pepperson 1536 1/2 W Locust 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. 2021-03-03 Amee Ann Pepperson amee0818@yahoo.com Davenport Scott Iowa Philip Gerald Hoxsey Michael Wayne Underdahl Signed (1) The corporation rejects the employers’ liability coverage. Amee A Pepperson amee0818@yahoo.com Self Davenport Scott Iowa Michael Wayne Underdahl Philip Gerald Hoxsey Signed
304 2021-08-07 03:43 Anonymous (not verified) 50.81.215.27 VALLE SERVICES LLC 6520 N DIVISION 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. 2021-08-07 LAURA VALLE iavalleservicesllc@gmail.com DAVENPORT IA United States bryon hakes celia valle Signed (1) The corporation rejects the employers’ liability coverage. LAURA VALLE iavalleservicesllc@gmail.com owner DAVENPORT IA United States bryon hakes celia valle Signed
500 2022-06-22 15:55 Anonymous (not verified) 206.125.132.254 Cozad Trucking Inc 2272 W River Dr, Davenport, IA 52802 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. 2022-06-22 David Cozad jeepd856@gmail.com Davenport Scott Iowa Brett Nelson Colleen Heiser Signed (1) The corporation rejects the employers’ liability coverage. David Cozad jeepd856@gmail.com Owner Davenport Scott IA Brett Nelson Colleen Heiser Signed
641 2023-03-29 08:15 Anonymous (not verified) 94.188.205.175 THERMOGRAPHIC Wellness 1000 N. West St, Suite 1200, Wilmington, DE 19801 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. 2023-03-29 Palmer Piana pianapal@gmail.com Davenport Scott County Iowa Olivia Piana Anthony Piana Signed (1) The corporation rejects the employers’ liability coverage. Olivia Piana joinbti@gmail.com VP of Operations Davenport Scott county IA Palmer Piana Anthony Piana Signed