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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:
179 2021-02-16 18:03 Anonymous (not verified) 216.248.123.206 Outer Edge Screen Printing 2449 68th Street Van Horne, Iowa 52346 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. 2021-02-16 Kyle Christopher Kline outedgekim@gmail.com Van Horne IA United States Kelsea Marie Kline Amber Marie Valentine Signed (1) The corporation rejects the employers’ liability coverage. Kimberly Sue Kline outedgekim@gmail.com spouse Van Horne IA United States Kelsea Marie Kline Amber Lynn Valentine Signed
180 2021-02-16 18:05 Anonymous (not verified) 216.248.123.206 Outer Edge Screen Printing 2449 68th Street Van Horne, Iowa 52346 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. 2021-02-16 Kimberly Sue Kline outedgekim@gmail.com Van Horne IA United States Amber Lynn Valentine Kelsea Marie Kline Signed (1) The corporation rejects the employers’ liability coverage. Outer Edge Screen Printing Co outedgekim@gmail.com Spouse Van Horne IA United States Amber Lynn Valentine Kelsea Marie Kline Signed
215 2021-03-29 07:58 Anonymous (not verified) 173.18.193.51 Lee County Fair, Inc PO Box 179 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. 2021-03-05 Dillon Benner judy@fullenkampins.com ARgyle IA United States Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Dillon Benner judy@fullenkampins.com Board Member Argyle IA United States Lindsey Lampe Judy Moeller Signed
216 2021-03-29 08:01 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 Bryan Bredemeyer judy@fullenkampins.com Bonaparte IA United States Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Brian Bredemeyer judy@fullenkampins.com Board Member Bonaparte IA United States Lindsey Lampe Judy Moeller Signed
231 2021-04-11 12:19 Anonymous (not verified) 174.243.115.140 Blaser Plumbing Inc 28933 Sieverding Ridge Rd Bellevue IA 52031 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-11 Michael Blaser bpi1999@hotmail.com Bellevue IA United States Joyce Langmeier Sylvester Langmeier Signed (1) The corporation rejects the employers’ liability coverage. Michael Blaser bpi1999@hotmail.com Owner Bellevue IA United States Joyce Langmeier Sylvester Langmeier Signed
236 2021-04-14 14:59 Anonymous (not verified) 75.89.76.245 Pillar Inc 906 W 18th St. Nevada, IA 50201 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-14 Jason J Burke jason@pillariowa.com Huxley IA United States Debbie Goetz John Goetz Signed (1) The corporation rejects the employers’ liability coverage. Matt Klucas matt@pillariowa.com VP Fort Dodge IA United States Debbie Goetz John Goetz Signed
242 2021-04-21 13:27 Anonymous (not verified) 198.14.211.149 Centerville Greenhouses 418 N. 5th Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-21 Alexander Joseph Lind alex@centervillegreenhouses.com Centerville IA United States John Douglas Hurley Dennis James Peters Signed (1) The corporation rejects the employers’ liability coverage. Peter Michael Lind peter@centervillegreenhouses.com President Centerville IA United States John Douglas Hurley Dennis James Peters Signed
243 2021-04-21 13:29 Anonymous (not verified) 198.14.211.149 Centerville Greenhouses 418 N. 5th Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-21 Peter Michael Lind peter@centervillegreenhouses.com Centerville IA United States John Douglas Hurley Dennis James Peters Signed (1) The corporation rejects the employers’ liability coverage. Alexander Joseph Lind alex@centervillegreenhouses.com Vice President Centerville IA United States John Douglas Hurley Dennis James Peters Signed
281 2021-06-30 10:59 Anonymous (not verified) 206.72.14.249 TCS Fabricating, Inc 315 Hwy 22 Keswick, IA 50136 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 Tom Sieren TCSFAB@NETINS.NET Keswick Keokuk Iowa Scott Grimm Amber Kephart Signed (1) The corporation rejects the employers’ liability coverage. Tom Sieren TCSFAB@NETINS.NET Vice President Keswick IA United States Scott Grimm Amber Kephart Signed
290 2021-07-26 12:29 Anonymous (not verified) 208.95.1.97 Chyma's Welding, Inc. 206 2nd Ave, Toledo IA 52342 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-08-01 Chad Chyma Chymamenwelding@windstream.net Toledo Tama IA Matt Zmolek Michaela Chyma Signed (1) The corporation rejects the employers’ liability coverage. Chad Chymamenwelding@windstream.net Director Toledo IA United States Matt Zmolek Michaela Chyma Signed
303 2021-08-06 10:12 Anonymous (not verified) 173.28.219.60 Travis Systems, Inc. 2060 Lynncrest 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. 2021-08-06 Travis Remmert travis@travissystems.com Coralville IA United States Michelle Remmert Christine Douglas Signed (1) The corporation rejects the employers’ liability coverage. Travis Remmert travis@travissystems.com President & CEO Coralville IA United States Michelle Remmert Christine Douglas 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
322 2021-08-27 16:16 Anonymous (not verified) 173.30.51.29 Waterfall Design LLC 3184 Berkshire Pkwy I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-02 John S Lanscak III waterfalldesign3@gmail.com Clive IA United States Joshua A Fisk Patricia A Fisk Signed (1) The corporation rejects the employers’ liability coverage. John S Lanscak III waterfalldesign3@gmail.com Owner/CEO Clive IA United States Joshua A Fisk Patricia A Fisk Signed
345 2021-10-11 15:36 Anonymous (not verified) 173.188.10.36 Outdoor Pros LLC 4525 HWY 22 SE 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. 2021-10-11 Erik Scott Alberhasky erikalberhas@gmail.com LONE TREE IA United States Melanie Hockenson Robin Morrison Signed (1) The corporation rejects the employers’ liability coverage. Erik Scott Alberhasky erikalberhas@gmail.com Owner LONE TREE IA United States Melanie Hockenson Robin Morrison Signed
371 2021-12-09 11:03 Anonymous (not verified) 216.81.176.153 Concentric International Inc. 1901 Bell Ave Ste 18, Des Moines, IA 50315-1067 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-12-09 Tracey Ball tball@ruan.com Urbandale IA United States Jackie Walker Craig Gesme Signed (1) The corporation rejects the employers’ liability coverage. Tracey Ball tball@ruan.com Treasurer Urbandale IA United States Jackie Walker Craig Gesme Signed
410 2022-02-20 19:10 Anonymous (not verified) 173.27.233.68 A and W marble and tile Inc 207 Philip St. Des Moines, Iowa 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. 2022-02-20 Wayne Yergy wyergy@gmail.com Des Moines Polk Iowa John Noga Angie Carter Signed (1) The corporation rejects the employers’ liability coverage. Wayne A Yergy wyergy@gmail.com Vice President Des Moines IA United States John Noga Angie Carter Signed
421 2022-03-07 17:14 Anonymous (not verified) 174.215.244.140 MJ Kunkel Trucking, LLC 403 N Ash St I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-07 Michael John Kunkel mjkunkeltrucks@gmail.com Marcus IA United States Adam Bartels Karlee Ohrt Signed (1) The corporation rejects the employers’ liability coverage. Michael John Kunkel mikekunkel0361@gmail.com Self Marcus IA United States Adam Bartels Karlee Ohrt Signed
498 2022-06-17 08:45 Anonymous (not verified) 64.5.79.180 The Sign Shed & Graphics LLC 529 Erie St, PO Box 252 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. 2022-05-26 Brent Ulrich signshed@yahoo.com Storm Lake IA United States Zach Ruroden Ryan Young Signed (1) The corporation rejects the employers’ liability coverage. Brent Ulrich signshed@yahoo.com CEO Storm Lake IA United States Zach Ruroden Ryan Young Signed
516 2022-07-19 15:43 Anonymous (not verified) 66.207.21.24 Frank Iliff 1424 B Houser Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-22 Frank Iliff rtmuscatine@gmail.com Muscatine IA United States Dewayne Hopkins James R. Bell Signed (1) The corporation rejects the employers’ liability coverage. Frank Iliff rtmuscatine@gmail.com Executive Director Muscatine IA United States Dewayne Hopkins James R. Bell Signed
517 2022-07-19 15:43 Anonymous (not verified) 66.207.21.24 Frank Iliff 1424 B Houser Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-07-22 Frank Iliff rtmuscatine@gmail.com Muscatine IA United States Dewayne Hopkins James R. Bell Signed (1) The corporation rejects the employers’ liability coverage. Frank Iliff rtmuscatine@gmail.com Executive Director Muscatine IA United States Dewayne Hopkins James R. Bell Signed
521 2022-07-25 15:33 Anonymous (not verified) 199.66.14.149 ROSENBERGER ENTERPRISES, INC. 1813 N 7th St INDIANOLA, IA 50125 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. 2022-07-25 Diane Rosenberger diane@katanainc.com Indianola IA United States SPRING CRUBAUGH BRADY FRY Signed (2) The corporation declines to reject the employers’ liability coverage. Diane Rosenberger diane@katanainc.com Owner Indianola IA United States SPRING CRUBAUGH BRADY FRY Signed
555 2022-10-06 17:48 Anonymous (not verified) 67.22.198.94 Baker Irrigation inc 2621 310th st I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-08 Daniel Brent Baker dan@bakerirrigationia.com ROCK VALLEY IA United States Adam Kooistra Alex De Jager Signed (1) The corporation rejects the employers’ liability coverage. Daniel Baker dan@bakerirrigationia.com President ROCK VALLEY IA United States Alex DeJager Adam Kooistra Signed
561 2022-11-03 11:24 Anonymous (not verified) 96.31.21.117 Northwest 9 Inc. 1512 Elmwood Ave. I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-03 Ethan Meyer ethanmeyer83@gmail.com ROCK RAPIDS Iowa United States Brad Meyer Trinda Meyer Signed (1) The corporation rejects the employers’ liability coverage. Brad Meyer nw9farm@gmail.com owner Rock Rapids IA United States Trinda Meyer Brad Meyer Signed
563 2022-11-09 10:28 Anonymous (not verified) 199.168.243.195 Mensingers Aquatic Resources, Inc. 2119 Oak Trail Drive 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. 2022-11-09 Jeff Mensinger jeffrey.mensinger@hdrinc.com Camanche ia United States Cody Mensinger Jeremiah Haas Signed (1) The corporation rejects the employers’ liability coverage. Jeff Mensinger jeffrey.mensinger@hdrinc.com President Camanche ia United States Cody Mensinger Jeremiah Haas Signed
591 2023-01-22 11:19 Anonymous (not verified) 216.106.211.176 Trackside Service & Repair Inc. 205 Main St. Alvord, IA 51230 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-22 Darwyn G Klarenbeek trackside@alliancecom.net Rock Rapids Lyon United States Steve Green Renee Klarenbeek Signed (1) The corporation rejects the employers’ liability coverage. Darwyn G Klarenbeek trackside@alliancecom.net Owner Rock Rapids IA United States Steve C. Green Renee J Klarenbeek Signed
594 2023-01-31 09:17 Anonymous (not verified) 70.58.136.161 Great Tree LLC 2701 e douglas ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-31 Robert buell Greattree55@gmail.com Des Moines IA United States Jamarlo alvarez Fields Amanda lee netolicky Signed (1) The corporation rejects the employers’ liability coverage. Robert buell Greattree55@gmail.com ceo/ company owner/ operator Des Moines IA United States Jamarlo Alvarez Fields Amanda Lee Netolicky Signed
596 2023-02-06 08:08 Anonymous (not verified) 107.121.104.18 Household Nanny 1357 Woolridge Dr., 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. 2023-02-06 Stephen John Statz sstatz32@gmail.com Coralville IA United States Jeffrey Peterson Casey Edwards Signed (1) The corporation rejects the employers’ liability coverage. Stephen John Statz sstatz32@gmail.com Owner Coralville IA United States Jeffrey Peterson Casey Edwards Signed
612 2023-02-24 08:02 Anonymous (not verified) 94.188.205.166 Ketter Household 3517 Witmer Pkwy I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-02-24 Sarah Jones Ketter sarahajones09@gmail.com Des Moines IA United States Christopher Ketter Stacia Fuller Signed (1) The corporation rejects the employers’ liability coverage. Sarah Jones Ketter sarahajones09@gmail.com Same Des Moines IA United States Christopher Ketter Stacia Fuller Signed
622 2023-03-08 13:40 Anonymous (not verified) 94.188.207.226 DDD Construction 624 west maple P.O.164 Allerton 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. 2023-03-08 Douglas Dean Downs tripledconstruction@hotmail.com ALLERTON IA United States June Lynette Downs William Lee Downs Signed (1) The corporation rejects the employers’ liability coverage. Douglas Dean Downs tripledconstruction@hotmail.com Coowner ALLERTON IA United States June Lynette Downs William Lee Downs Signed
623 2023-03-08 13:48 Anonymous (not verified) 94.188.205.174 Jim & Laini's Trucking Inc 11591 Rupp Hollow 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. 2023-03-08 James Harry jltiowa@gmail.com DUBUQUE IA United States Christopher T Clarke Chris Clarke Signed (1) The corporation rejects the employers’ liability coverage. James Harry jltiowa@gmail.com owner DUBUQUE IA United States Christopher T Clarke Chris Clarke Signed
624 2023-03-08 13:50 Anonymous (not verified) 94.188.205.177 Jim & Laini's Trucking Inc 11591 Rupp Hollow 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. 2023-03-08 Elaine Harry jltiowa@gmail.com DUBUQUE Iowa United States Christopher T Clarke Chris Clarke Signed (1) The corporation rejects the employers’ liability coverage. James Harry jltiowa@gmail.com owner DUBUQUE IA United States Christopher T Clarke Chris Clarke Signed
630 2023-03-21 21:32 Anonymous (not verified) 94.188.205.169 S & O Builders, LLC 201 NW 10th Circle, Grimes, IA 50111 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. 2023-03-21 Benjamin Olson sandobuilders@gmail.com Grimes IA IA Brad Fasse Nate Estes Signed (1) The corporation rejects the employers’ liability coverage. Benjamin Olson sandobuilders@gmail.com Co-Owner Grimes IA IA Brad Fasse Nate Estes Signed
633 2023-03-22 14:36 Anonymous (not verified) 94.188.205.175 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 Scott Edwards Scott@imperialia.com Norwalk Iowa IA Jesus San Elias Tim Mullin Signed (1) The corporation rejects the employers’ liability coverage. Scott Edwards scott@imperialia.com Owner NORWALK IA United States Jesus San Elias Tim Mullin 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
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
657 2023-04-20 11:33 Anonymous (not verified) 94.188.205.177 Debra Higgins 201 Cedar 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. 2023-04-20 Debra Higgins diggs0519@icloud.com Slater IA United States Howard Higgins Howard Higgins Signed (1) The corporation rejects the employers’ liability coverage. Debra Higgins diggs0519@icloud.com owner Slater IA United States Howard Higgins Howard Higgins Signed
658 2023-04-20 11:39 Anonymous (not verified) 94.188.205.167 Old Pros Consulting Inc 201 Cedar St Slater Iowa 50244 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. 2023-04-20 Debra Higgins diggs0519@icloud.com Slater IA United States Howard Higgins Howard Higgins Signed (1) The corporation rejects the employers’ liability coverage. Debra Higgins diggs0519@icloud.com owner Slater IA United States Howard Higgins Howard Higgins Signed
659 2023-04-21 13:58 Anonymous (not verified) 94.188.205.168 Streamline Plumbing LLC 1513 Nw 8th St Grimes, IA 50111 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2023-04-21 Benjamin Molloy slplumbing.llc@gmail.com Grimes IA United States Christine Darnell Steven Perona Signed (2) The corporation declines to reject the employers’ liability coverage. Benjamin Molloy slplumbing.llc@gmail.com owner Grimes IA United States Christine Darnell Steven Perona Signed
660 2023-04-26 07:56 Anonymous (not verified) 94.188.207.227 Darrin Hearn DBA GoodCauseMinis 445 Onyx Ave Marion IA 52302 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. 2023-04-26 Darrin Hearn goodcauseminis@gmail.com Marion IA United States Darrin Hearn Darrin Hearn Signed (1) The corporation rejects the employers’ liability coverage. Darrin Hearn goodcauseminis@gmail.com owner Marion IA United States Darrin Hearn Darrin Hearn Signed
680 2023-06-06 16:43 Anonymous (not verified) 94.188.205.167 Great Tree LLC 2701 e douglas ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-06 Timothy william Buell tbuell52@gmail.com Des Moines IA United States tyler smith Jamarlo fields Signed (1) The corporation rejects the employers’ liability coverage. Robert buell Greattree55@gmail.com company owner Des Moines IA United States jamarlo fields tyler Smith Signed
694 2023-06-20 13:25 Anonymous (not verified) 94.188.207.229 Canvas Products Co. 182 Main Street Dubuque, Iowa 52001 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-20 Frank Salwolke frank@dbqcanvas.com Dubuque IA Iowa Ashley A. Trowbridge Taylor J. Trowbridge Signed (1) The corporation rejects the employers’ liability coverage. frank salwolke frank@dbqcanvas.com President DUBUQUE IA Iowa Ashley A. Trowbridge Taylor J. Trowbridge Signed
695 2023-06-20 13:27 Anonymous (not verified) 94.188.207.227 Canvas Products Co. 182 Main Street Dubuque, Iowa 52001 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-20 Mary A.Salwolke maryann@dbqcanvas.com Dubuque IA Iowa Ashley A. Trowbridge Taylor J. Trowbridge Signed (1) The corporation rejects the employers’ liability coverage. Frank J. Salwolke frank@dbqcanvas.com President Dubuque Ia Iowa Ashley A. Trowbridge Taylor J. Trowbridge Signed
696 2023-06-20 13:30 Anonymous (not verified) 94.188.207.226 Canvas Products Co. 182 Main Street Dubuque, Iowa 52001 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-20 Jacob I. Salwolke jake@dbqcanvas.com sherrill IA Iowa Ashley A. Trowbridge Taylor J. Trowbridge Signed (1) The corporation rejects the employers’ liability coverage. Frank J. Salwolke frank@dbqcanvas.com President dubuque IA Iowa Ashley A. Trowbridge Taylor J. Trowbridge Signed
700 2023-06-22 11:03 Anonymous (not verified) 94.188.207.229 WIT Systems Corporation 313 Brentwood Dr NE, Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-22 DOUGLAS K WILLIAMS dkwilliams@witsystems.com Cedar Rapids IA Linn CT Patrick Gavin Kaley Gavin Signed (1) The corporation rejects the employers’ liability coverage. DOUGLAS K WILLIAMS dkwilliams@witsystems.com President CEDAR RAPIDS IA United States Patrick Gavin Kaley Gavin Signed
701 2023-06-22 15:06 Anonymous (not verified) 94.188.205.166 Des Moines Contractors 833 Buchanan st Des Moines ia 50316 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-22 Maison Wayne Miller DesMoinesContractors@gmail.com Des Moines Polk Iowa Kent Sorenson Krista Sheriff Signed (1) The corporation rejects the employers’ liability coverage. Maison Wayne Miller DesMoinescontractors@gmail.com Owner Des moines IA United States Kent Sorenson Krista Sheriff Signed
714 2023-07-25 16:16 Anonymous (not verified) 94.188.207.224 Midwest Systems 2877 130th St Aurora, Ia 50607 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-25 Matt Griswold midwestsystems@live.com Aurora IA United States Creatleigh Griswold Carslyn Griswold Signed (1) The corporation rejects the employers’ liability coverage. Matt Griswold midwestsystems@live.com Owner Aurora IA United States Creatleigh Griswold Carslyn Griswold Signed
715 2023-07-26 11:23 Anonymous (not verified) 94.188.207.226 Lampe Appliance Service, Inc 210 29th St NE, Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-26 Douglas James Lampe lampeappliance@gmail.com Cedar Rapids Linn IA John Kenneth Lampe Jared Joshua Lampe Signed (1) The corporation rejects the employers’ liability coverage. Douglas James Lampe lampeappliance@gmail.com President CEDAR RAPIDS IA United States John Kenneth Lampe Jared Joshua Lampe Signed
716 2023-07-26 11:27 Anonymous (not verified) 94.188.207.228 Lampe Appliance Service, Inc 210 29th St NE, Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-26 John Kenneth Lampe lampeappliance@gmail.com CEDAR RAPIDS Linn Iowa Douglas James Lampe Jared Joshua Lampe Signed (1) The corporation rejects the employers’ liability coverage. Douglas James Lampe lampeappliance@gmail.com President CEDAR RAPIDS IA United States John Kenneth Lampe Jared Joshua Lampe Signed
740 2023-08-14 10:25 Anonymous (not verified) 94.188.205.167 Absolute Mud Jacking Inc 5038 Brittany Ct Bettendorf Iowa 52722 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. 2023-08-12 Paul Pelzer pelzer830@gmail.com Bettendorf IA United States Brett Lewandowski Phil Schaefer Signed (1) The corporation rejects the employers’ liability coverage. Paul Pelzer pelzer830@gmail.com Owner Bettendorf IA United States Brett Lewandowski Phil Schaefer Signed