159 |
2021-01-12 09:00 |
Anonymous (not verified) |
72.13.20.192 |
RTA TRUCKING LLC |
31504 E Worthington Rd, Worthington, IA 52078 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-01-12 |
Kirk Pleggenkuhle dba Pleggenkuhle Pride Inc. |
kirkpleggenkuhle@gmail.com |
Mingo |
Jasper |
IA |
Rod Jaeger |
Jennie Jaeger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jennie Jaeger |
rtatruck@gmail.com |
office manager |
Worthington |
IA |
United States |
Rod Jaeger |
Kirk Pleggenkuhle |
Signed |
843 |
2023-12-23 11:45 |
Anonymous (not verified) |
94.188.205.177 |
Janssen Handyman Service LLC |
503 Cherry Ave. Woodward, IA 50276 |
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 |
Cody A. Janssen |
janssenhandyman86@gmail.com |
Woodward |
Iowa |
Iowa |
Stephenie Janssen |
Glen Hall |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cody A. Janssen |
janssenhandyman86@gmail.com |
Owner |
Woodward |
Iowa |
Iowa |
Stephenie Janssen |
Glen Hall |
Signed |
559 |
2022-10-24 15:14 |
Anonymous (not verified) |
108.178.192.251 |
LogicBox, Inc. |
2381 Highway 169, Winterset, IA 50273 |
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. |
2022-10-24 |
Jeremy Goemaat |
jeremy.goemaat@gmail.com |
Winterset |
Madison |
Iowa |
Janelle Goemaat |
Gunnar Goemaat |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeremy Goemaat |
jeremy.goemaat@gmail.com |
CEO/Owner |
Winterset |
Madison |
Iowa |
Janelle Goemaat |
Gunnar Goemaat |
Signed |
681 |
2023-06-07 12:28 |
Anonymous (not verified) |
94.188.205.166 |
Staley Tile |
328 South 4th 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. |
2023-06-07 |
Scott Wayne Staley |
staleyscott@yahoo.com |
Winterset |
Madison |
Iowa |
Michelle Rene Baker |
Mario DeMarco |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott Wayne Staley |
staleyscott@yahoo.com |
Owner |
Winterset |
Madison |
Iowa |
Michelle Rene Baker |
Mario DeMarco |
Signed |
846 |
2024-01-03 14:13 |
Anonymous (not verified) |
94.188.205.168 |
Madison County Renovations Inc |
PO Box 521, Winterset, IA 50273 |
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. |
2024-01-03 |
Jonathan Hays |
17jhays@gmail.com |
Waukee |
Dallas |
IA |
Rachel Anderson |
Roger Queck |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mark Hays |
mark.hays88@yahoo.com |
President |
Winterset |
Madison |
Iowa |
Rachel Anderson |
Roger Qyeck |
Signed |
133 |
2020-11-15 19:57 |
Anonymous (not verified) |
75.162.166.182 |
A Metro Snow Removal and lawn care llc |
6436 Washington 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. |
2020-11-15 |
Jeff Lamp |
Jeff.lamp79@gmail.com |
Windsor hieghts |
IA |
United States |
Jill Fresh |
Rick Brown |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
A Metro Snow Removal and lawn Care llc |
Jeff.lamp79@gmail.com |
Owner |
Windsor hieghts |
IA |
United States |
jill Fresh |
Rick Brown |
Signed |
776 |
2023-10-02 07:19 |
Anonymous (not verified) |
94.188.205.176 |
Silver Fox Construction |
1238 71st |
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. |
2023-10-02 |
Scott Klinkefus |
scott.klinkefus@gmail.com |
Windsor Heights |
Iowa |
United States |
Kristin Brantley |
Matt Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott Klinkefus |
scott.klinkefus@gmail.com |
Same |
Windsor Heights |
Iowa |
United States |
Kristin Brantley |
Matt Jones |
Signed |
527 |
2022-08-18 12:44 |
Anonymous (not verified) |
75.146.219.201 |
James F. Valentine, Inc. |
300 Thomas Avenue, Bldg 401, Williamstown, NJ 08094 |
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. |
2022-08-18 |
James F. Valentine |
jvalentine@valentineassoc.com |
Williamstown |
Gloucester |
New Jersey |
Kim Vona |
Dawn Souder |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James F Valentine |
jvalentine@valentineassoc.com |
Owner |
Williamstown |
Gloucester |
New Jersey |
Kim Vona |
Dawn Souder |
Signed |
528 |
2022-08-22 15:57 |
Anonymous (not verified) |
75.146.219.201 |
James F. Valentine |
300 Thomas Avenue, Bldg 401, Williamstown, NJ 08094 |
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. |
2022-08-22 |
James F. Valentine |
jvalentine@valentineassoc.com |
Williamstown |
Gloucester |
New Jersey |
Kim Vona |
Dawn Souder |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James F. Valentine |
jvalentine@valentineassoc.com |
Owner |
Williamstown |
Gloucester |
New Jersey |
Kim Vona |
Dawn Souder |
Signed |
499 |
2022-06-22 03:40 |
Anonymous (not verified) |
64.251.168.116 |
VALBURG AERIAL SPRAYING INC. |
27656 SD Hwy 44 WHITE RIVER SD 57579 |
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. |
2022-06-19 |
Dan A Valburg |
agflyer620@gwtc.net |
White River |
SD |
SD |
LANDON HOSSLE |
JOSH HICKS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dan A Valburg |
agflyer620@gwtc.net |
PRESIDENT |
White River |
SD |
SD |
LANDON HOSSLE |
JOSH HICKS |
Signed |
482 |
2022-06-02 08:25 |
Anonymous (not verified) |
173.18.193.51 |
Wever Fire Association |
1692 354th Avenue, Wever, Iowa 52658 |
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. |
2022-05-24 |
Bill Brookhiser |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill Brookhiser |
judy@fullenkampins.com |
Board Member |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
483 |
2022-06-02 08:28 |
Anonymous (not verified) |
173.18.193.51 |
Wever Fire Association |
1692 354th Avenue, Wever, Iowa 52658 |
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. |
2022-05-24 |
Deb Sylvester |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Deb Sylvester |
judy@fullenkampins.com |
Secretary / Treasurer |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
484 |
2022-06-02 08:31 |
Anonymous (not verified) |
173.18.193.51 |
Wever Fire Association |
1692 354th Avenue, Wever, Iowa 52658 |
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. |
2022-05-24 |
Gregory Liddle |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
judy moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gregory Liddle |
judy@fullenkampins.com |
President |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
485 |
2022-06-02 08:33 |
Anonymous (not verified) |
173.18.193.51 |
Wever Fire Association |
1692 354th Avenue, Wever, Iowa 52658 |
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. |
2022-05-24 |
Hugh Vandgriff |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Hugh Vandegriff |
Judy@fullenkampins.com |
board member |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
486 |
2022-06-02 08:34 |
Anonymous (not verified) |
173.18.193.51 |
Wever Fire Association |
1692 354th Avenue, Wever, Iowa 52658 |
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. |
2022-05-24 |
Craig Pieper |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Craig Pieper |
Judy@fullenkampins.com |
Vice President |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
487 |
2022-06-02 08:36 |
Anonymous (not verified) |
173.18.193.51 |
Wever Fire Association |
1692 354th Avenue, Wever, Iowa 52658 |
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. |
2022-05-25 |
Jacob Denning |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jacob Denning |
judy@fullenkampins.com |
Board Member |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
333 |
2021-09-14 14:53 |
Anonymous (not verified) |
147.0.156.50 |
O'Danny Boy Builders, Inc. |
7512 S. County Line Rd., Suite #4, Burr Ridge, IL 60527 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-14 |
Daniel Flanagan |
jflanagan@odannyboybuilders.com |
LaGrange |
Cook |
Illinois |
John Flanagan |
Mark Hayes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Flanagan |
Jflanagan@odannyboybuilders.com |
Executive |
Western Springs |
Cook |
IL |
Ben Weed |
Mark Hayes |
Signed |
221 |
2021-03-29 08:08 |
Anonymous (not verified) |
173.18.193.51 |
Lee County Fair, Inc |
PO Box 179, Donnellson, 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 |
Dustin Overberg |
judy@fullenkampins.com |
West Point |
Lee |
Iowa |
Lindsey Lampe |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dustin Overberg |
judy@fullenkampins.com |
President |
West Point |
Lee |
Iowa |
Lindsey Lampe |
Judy Moeller |
Signed |
222 |
2021-03-29 08:09 |
Anonymous (not verified) |
173.18.193.51 |
Lee County Fair, Inc |
PO Box 179, Donnellson, 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 |
Melanie Kramer |
judy@fullenkampins.com |
West Point |
Lee |
Iowa |
Lindsey Lampe |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Melanie Kramer |
judy@fullenkampins.com |
Secretary |
West Point |
Lee |
Iowa |
Lindsey Lampe |
Judy Moeller |
Signed |
229 |
2021-04-05 13:44 |
Anonymous (not verified) |
173.18.193.51 |
Denmark Sanitary District |
PO Box 141, Denmark, Iowa 52624 |
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. |
2021-04-03 |
Clay Fullenkamp |
judy@fullenkampins.com |
West Point |
Lee |
Iowa |
Judy Moeller |
Brian Stuekerjuergen |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Clay Fullenkamp |
judy@fullenkampins.com |
Board Member |
West Point |
Lee |
Iowa |
judy moeller |
brian stuekerjuergen |
Signed |
65 |
2020-04-20 13:37 |
Anonymous (not verified) |
173.24.181.211 |
Historic Arnolds Park Inc |
37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 |
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. |
2020-04-01 |
Denny Walker |
jennifer@walkerinsuranceia.com |
West Okoboji |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Denny Walker |
jennifer@walkerinsuranceia.com |
Board Member |
West Okoboji |
Dickinson |
Iowa |
Joseph Thomas Loring |
Jennifer Janet Youngwirth |
Signed |
675 |
2023-05-24 07:55 |
Anonymous (not verified) |
94.188.207.223 |
Sierra Roofing |
401 W 15th Street West Liberty, IA 52776 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-05-24 |
Abraham Granjeno Sierra |
sierraroofing@gmail.com |
West Liberty |
Muscatine |
Iowa |
Cody Thorpe |
Claudia Venable |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Abraham Granjeno Sierra |
sierraroofing@gmail.com |
Owner/Self |
West Liberty |
Muscatine |
Iowa |
Cody Thorpe |
Claudia Venable |
Signed |
893 |
2024-02-22 10:29 |
Anonymous (not verified) |
94.188.207.226 |
Sierra Roofing |
401 W 15th Street West Liberty, IA 52776 |
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. |
2024-02-22 |
Abraham Granjeno Sierra |
absierra89@gmail.com |
West Liberty |
Muscatine |
Iowa |
Claudia Venable |
Dan Saunders |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Abraham Granjeno Sierra |
absierra89@gmail.com |
Owner/Self |
West Liberty |
Muscatine |
Iowa |
Claudia Venable |
Dan Saunders |
Signed |
917 |
2024-03-11 12:51 |
Anonymous (not verified) |
94.188.205.168 |
Hernandez Construction KD |
119 W Maxson 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. |
2024-03-11 |
Juan Santiago Hernandez |
chagodoki74@gmail.com |
West Liberty |
Muscatine |
Iowa |
Kevin Kofron |
Kiara Hernandez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Juan Santiago Hernandez |
chagodoki74@gmail.com |
Owner |
West Liberty |
Muscatine |
Iowa |
Kevin Kofron |
Kiara Hernandez |
Signed |
780 |
2023-10-04 16:18 |
Anonymous (not verified) |
94.188.207.228 |
Premier Staffing Agency |
6887 Dakota drive West Desmoines Iowa 50266 |
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. |
2023-10-10 |
Felistas Kimani |
mwangifelistas4@gmail.com |
West Desmoines |
Dallas |
Iowa |
Denis Waweru |
George Komu |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Felistas Kimani |
mwangifelistas4@gmail.com |
member |
West Desmoines |
Dallas |
Iowa |
Denis Waweru |
George Komu |
Signed |
288 |
2021-07-22 16:17 |
Anonymous (not verified) |
104.166.243.230 |
Renewal By Anderson |
517 railroad ave. West Des Moines |
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. |
2021-07-22 |
Cameron Thede |
camthede22@gmail.com |
Windsor Heights |
Polk |
Iowa |
Mac Laven |
sdofkn |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Renewal By Andersen |
james@rbadesmoines.com |
Subcontractor |
West Des Moines |
Polk |
IA |
Mac Laven |
lsdfkn lsadnf |
Signed |
420 |
2022-03-04 13:58 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise LLC |
101 Ashworth 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. |
2022-03-04 |
Mustafa Keserovic |
MustafaKeserovic@gmail.com |
Ankeny |
Pokl |
Iowa |
Sandro Tadic |
Andrew Swanson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandro Tadic |
sanienterprise14@gmail.com |
Owner |
WEST DES MOINES |
Iowa |
United States |
Sandro Tadic |
Andrew swanson |
Signed |
634 |
2023-03-22 14:40 |
Anonymous (not verified) |
94.188.205.167 |
Guardian Real Estate Inspection Services LLc |
2623 Shady Lane Dr Norwalk, Iowa 50211 |
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. |
2023-03-22 |
Joseph D Nelson |
scott@imperialia.com |
West Des Moines |
Polk |
Iowa |
Pedro Antonio |
Steve Flynn |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Neslon |
Scott@imperialia.com |
Owner |
West Des Moines |
IA |
Iowa |
Steve Flynn |
Pedro Antonio |
Signed |
643 |
2023-03-30 09:58 |
Anonymous (not verified) |
94.188.205.175 |
Adamantine Spine Moving |
2726 Independence Rd., Iowa City, IA 52240 |
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. |
2023-03-30 |
Emily Wallace |
emily.wallace@spinemoving.com |
Des Moines |
Polk |
Iowa |
John Wallace |
Ashley Koch |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ashley Koch |
ashley.koch@spinemoving.com |
Human Resources Manager |
West Des Moines |
Polk |
Iowa |
John Wallace |
Taylor Roth |
Signed |
958 |
2024-04-17 13:16 |
Anonymous (not verified) |
94.188.207.223 |
1st Choice Builders |
10095 Hickman Ct #2 |
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. |
2024-04-17 |
Scott Todd |
scott.todd85@yahoo.com |
West Des Moines |
Polk |
Iowa |
Danielle Pryor |
Ronnie Lee Todd |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott Todd |
scott.todd85@yahoo.com |
self |
West Des Moines |
Polk |
Iowa |
Danielle Pryor |
Ronnie Lee Todd |
Signed |
276 |
2021-06-17 16:00 |
Anonymous (not verified) |
204.155.61.217 |
Gentle Bend Inc |
1075 120th Street Wellman, IA 52356 |
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 |
Greg Gent |
gentagincorporated@gmail.com |
Wellman |
Washington |
Iowa |
Jeff Spenner |
Shawn Powell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Greg Gent |
gentagincorporated@gmail.com |
Owner |
Wellman |
Washington |
Iowa |
Jeff Spenner |
Shawn Powell |
Signed |
474 |
2022-05-16 16:25 |
Anonymous (not verified) |
208.126.193.1 |
Gentle Bend Inc. |
1075 120th Street, Wellman, Iowa 52356 |
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. |
2022-05-16 |
Georgia Gent |
ggent83@gmail.com |
Wellman |
Washington |
Iowa |
Jeff Spenner |
Shawn Powell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Georgia Gent |
ggent83@gmail.com |
owner |
Wellman |
Washington |
Iowa |
Jeff Spenner |
Shawn Powell |
Signed |
491 |
2022-06-06 09:32 |
Anonymous (not verified) |
24.118.76.144 |
Minnesota Restoration Contractors Inc. DBA MNRC |
12252 Nicollet Ave Burnsville, MN 55337 |
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 |
Daniel Lewis Lillestol |
info@mnrcinc.com |
Wayzata |
MN |
United States |
Karina Bazhenova |
MICHELLE LILLESTOL |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Lewis Lillestol |
info@mnrcinc.com |
CEO |
Wayzata |
Hennnepin |
MN |
Karina Bazhenova |
MICHELLE LILLESTOL |
Signed |
779 |
2023-10-04 07:14 |
Anonymous (not verified) |
94.188.207.225 |
CanD Homes, LLC |
1147 Leitha Ter, Waverly, IA 50677 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-04 |
Alexander Eckard-Lewis |
alex.lewis@candhomes.com |
Waverly |
Bremer |
IA |
Connor Eustice |
Victor Sanders |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Alexander Eckard-Lewis |
alex.lewis@candhomes.com |
Vice President |
Waverly |
Bremer |
IA |
Connor Eustice |
Victor Sanders |
Signed |
87 |
2020-06-09 14:49 |
Anonymous (not verified) |
185.169.109.170 |
Sweeney Builders Inc |
511 8th Ave NW |
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. |
2020-06-09 |
Michael Lee Sweeney |
mike@sweeneybuilders.com |
Waukon |
Allamakee |
Iowa |
Shawna Sweeney |
Jean Gavin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Shawna Sweeney |
shawna@sweeneybuilders.com |
Vice President |
Waukon |
Allamakee |
IA |
Mike Sweeney |
Jean Gavin |
Signed |
349 |
2021-10-22 11:08 |
Anonymous (not verified) |
63.152.48.235 |
Strong Rock and Gravel LLC |
721 S Front St, Lansing, IA 52151 |
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. |
2021-09-04 |
Ronald Strong |
stronggravel@gmail.com |
Llansing |
Allamakee |
Iowa |
James H Bieber |
Jane Tepesch |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James H Bieber |
biebinre@qwestoffice.net |
Insurance Agent |
WAUKON |
Allamakee |
Iowa |
James H Bieber |
Jane Tepesch |
Signed |
24 |
2020-01-02 09:12 |
Anonymous (not verified) |
207.191.194.182 |
Waukee CabinetWorks LLC |
70 SE Laurel St, Waukee IA 50263 |
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. |
2019-12-23 |
Amy Balm |
chris.rappe@waukeecabinetworks.com |
Waukee |
Dallas |
Iowa |
Chris Andrews |
Dave Creighton Sr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chris Rappe |
chris.rappe@waukeecabinetworks.com |
Operations Manager |
Waukee |
Dallas |
IA |
Chris Andrews |
Dave Creighton SR |
Signed |
25 |
2020-01-02 09:17 |
Anonymous (not verified) |
207.191.194.182 |
Waukee CabinetWorks LLC |
70 SE Laurel St, Waukee IA 50263 |
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. |
2019-12-23 |
Jason Balm |
chris.rappe@waukeecabinetworks.com |
Waukee |
Dallas |
Iowa |
Chris Andrews |
Dave Creighton Sr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chris Rappe |
chris.rappe@waukeecabinetworks.com |
Operations Manager |
Waukee |
Dallas |
Iowa |
Chris Andrews |
Dave Creighton SR |
Signed |
43 |
2020-02-28 09:50 |
Anonymous (not verified) |
173.24.140.77 |
W R Main Contractor Inc |
1620 NW 78th Street, Clive, IA 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. |
2020-02-28 |
Cindy Jo Ohmart |
co4mainco@aol.com |
West Des Moines |
Polk |
Iowa |
Jill Ann Reber |
Alane Marguerite Richardson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mark I Main |
markmain@icloud.com |
President |
Waukee |
Dallas |
Iowa |
Jill Ann Reber |
Alane Marguerite Richardson |
Signed |
469 |
2022-05-12 11:38 |
Anonymous (not verified) |
173.23.25.243 |
RS- Remodelers |
2863 104th St Urbandale IA 50322 |
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. |
2022-05-12 |
Stephen Dillon |
clearchoicedesmoinesia@gmail.com |
Waukee |
Dallas |
IA |
Rob Nevitt |
Jordan Nevitt |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Stephen |
clearchoicedesmoinesia@gmail.com |
Owner |
Waukee |
Dallas |
IA |
Rob Nevitt |
Jordan Nevitt |
Signed |
510 |
2022-07-12 09:13 |
Anonymous (not verified) |
174.198.70.141 |
Premiere Painting, LLC |
865 NE Bobcat Dr Waukee, IA. 50263 |
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. |
2022-07-12 |
Scott McVay |
scottkmcvay@live.com |
Waukee |
Dallas |
Iowa |
Robert Ferguson |
Christina Pham |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott McVay |
scottkmcvay@live.con |
Owner |
Waukee |
Dallas |
Iowa |
Robert Ferguson |
Christina Pham |
Signed |
538 |
2022-09-21 17:04 |
Anonymous (not verified) |
174.198.67.151 |
Premiere Painting, LLC |
865 NE Bobcat 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. |
2022-09-21 |
Scott McVay |
premierepainting515@gmail.com |
Waukee |
Dallas |
Iowa |
Christina Pham |
Robert Ferguson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott McVay |
premierepainting515@gmail.com |
Owner |
Waukee |
Dallas |
Iowa |
Christina Pham |
Robert Ferguson |
Signed |
637 |
2023-03-23 15:53 |
Anonymous (not verified) |
94.188.207.229 |
Pacifica Health Services, LLC |
4911 SW 19th St, Des Moines, IA 50315 |
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. |
2023-03-23 |
Jennifer Conner |
jconner@viahealthservices.com |
Des Moines |
Polk |
IA |
Jackie Hastings |
Amber Perdue |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kevin Babb |
kbabb@viahealthservices.com |
CEO |
Waukee |
Dallas |
IA |
Jackie Hastings |
Amber Perdue |
Signed |
640 |
2023-03-28 18:28 |
Anonymous (not verified) |
94.188.205.174 |
SM TILE DESIGN LLC |
670 Daybreak 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. |
2023-03-28 |
Samir Mulalic |
smtiledesign@gmail.com |
Waukee |
Iowa |
United States |
Samir Mulalic |
Saneta Dzankovic |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Samir Mulalic |
smtiledesign@gmail.com |
Owner |
Waukee |
Iowa |
United States |
Samir Mulalic |
Saneta Dzankovic |
Signed |
702 |
2023-06-27 07:04 |
Anonymous (not verified) |
94.188.207.230 |
Dancom Inc |
1001 Office Park Rd, West Des Moines, IA 50265 |
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. |
2023-06-26 |
Daniel Otundo |
daniel@dancoms.com |
Waukee |
Polk |
IA |
Joe Meyers |
Robert Simmons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Otundo |
daniel@dancoms.com |
Owner |
Waukee |
Polk |
IA |
Robert Simmons |
Joe Meyers |
Signed |
703 |
2023-06-27 07:05 |
Anonymous (not verified) |
94.188.207.229 |
Dancom Inc |
1001 Office Park Rd, West Des Moines, IA 50265 |
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. |
2023-06-26 |
Calvin Otundo |
calvin@dancoms.com |
Waukee |
Polk |
IA |
Joe Meyers |
Robert Simmons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Calvin Otundo |
calvin@dancoms.com |
Owner |
Waukee |
Polk |
IA |
Robert Simmons |
Joe Meyers |
Signed |
722 |
2023-08-01 11:55 |
Anonymous (not verified) |
94.188.207.229 |
SM TILE DESIGN LLC |
670 Daybreak 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. |
2023-08-01 |
Samir Mulalic |
smtiledesign@gmail.com |
Waukee |
Iowa |
United States |
Samir Mulalic |
Saneta Dzankovic |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Samir Mulalic |
smtiledesign@gmail.com |
Owner |
Waukee |
Iowa |
United States |
Samir Mulalic |
Saneta Dzankovic |
Signed |
775 |
2023-10-01 10:35 |
Anonymous (not verified) |
94.188.205.169 |
Prem Krishnan Menon Mohan Kumar |
460 NW Gracewood Dr, Waukee, IA 50263 |
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. |
2023-10-01 |
Prem Krishnan Menon Mohan Kumar |
premkrishnan@gmail.com |
Waukee |
Dallas |
Iowa |
Dileep Vasudevan |
Roy Shashidharan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Prem Krishnan Menon Mohan Kumar |
premkrishnan@gmail.com |
Owner |
Waukee |
Dallas |
Iowa |
Dileep Vasudevan |
Roy Shashidharan |
Signed |
946 |
2024-04-04 11:53 |
Anonymous (not verified) |
94.188.205.169 |
Soto Stone LLC |
1071 Mansfield dr waukee iowa 50263 |
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. |
2024-04-04 |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
Waukee |
DALLAS |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
Self |
Waukee |
Dallas |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
Signed |
763 |
2023-09-05 12:31 |
Anonymous (not verified) |
94.188.205.168 |
Blue Ridge Enterprises, LLC |
604 old sixteen road Waterville, IA 52170 |
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. |
2023-09-05 |
Nathan Eldon Leas |
nleas69@gmail.com |
Waterville |
Allamakee |
Iowa |
Mark Wright |
Gary Mahr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nathan Eldon Leas |
nleas69@gmail.com |
President/owner |
Waterville |
Allamakee |
Iowa |
Mark Wright |
Gary Mahr |
Signed |