927 |
2024-03-20 23:27 |
Anonymous (not verified) |
94.188.205.177 |
RRB, LLC |
4444 1st Ave NE Ste 510 Cedar Rapids, IA 52402 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-20 |
Kelli Holton |
kelli@rebelroseboutique.co |
Coralville |
IA |
United States |
Dave Booth |
Ann Holton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kelli Holton |
kelli@rebelroseboutique.co |
Owner |
Coralville |
IA |
United States |
Dave Booth |
Ann Holton |
Signed |
942 |
2024-04-03 12:06 |
Anonymous (not verified) |
94.188.205.174 |
Invisible Fence of NCI, Inc |
408 5th St, Ste 100 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-04 |
Lisa Busch Timm |
centraliowa@invisiblefence.com |
Madrid |
Iowa |
United States |
Paul Timm |
Kari Rigby |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Busch Timm |
centraliowa@invisiblefence.com |
Self |
Madrid |
IA |
United States |
Paul Timm |
Kari Rigby |
Signed |
943 |
2024-04-03 12:07 |
Anonymous (not verified) |
94.188.205.166 |
Invisible Fence of NCI, Inc |
408 5th St, Ste 100 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-04 |
Paul Andy Timm |
ifbcentraliowa@yahoo.com |
Madrid |
IA |
Iowa |
Lisa Timm |
Kari Rigby |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Busch Timm |
centraliowa@invisiblefence.com |
Spouse |
Madrid |
IA |
United States |
Lisa Timm |
Kari Rigby |
Signed |
945 |
2024-04-03 20:00 |
Anonymous (not verified) |
94.188.207.229 |
Timberview Construction |
803 TIMBERVIEW DR |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-03 |
Parker Evans |
Pcevans28@gmail.com |
ADEL |
IA |
United States |
jason Evans |
Tricia Evans |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Timberview Construction |
Pcevans28@gmail.com |
Myself |
ADEL |
IA |
United States |
Jason Evans |
Tricia Evans |
Signed |
949 |
2024-04-05 20:16 |
Anonymous (not verified) |
94.188.207.223 |
Viramontes Quality Lawncare LLC. |
3029 E Washington Ave Des Moines,Iowa 50317 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-05 |
Andres Viramontes Barron |
a.viramontes1989@gmail.com |
Des Moines |
Iowa |
United States |
Clayton Garrison |
Gloria Cardenas |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andres Viramontes |
a.viramontes1989@gmail.com |
owner |
Des Moines |
Iowa |
United States |
Clayton Garrison |
Gloria Cardenas |
Signed |
951 |
2024-04-08 10:59 |
Anonymous (not verified) |
94.188.205.167 |
McBee Trucking, LLC |
5029 HARDING 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. |
2024-04-08 |
Gary McBee |
accounting@mcbeetrucking.com |
Prole |
Warren |
Iowa |
Gary McBee |
Elizabeth Reid |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
GARY MCBEE |
gary@mcbeetrucking.com |
Owner |
PROLE |
IA |
United States |
GARY MCBEE |
Elizabeth Reid |
Signed |
952 |
2024-04-08 17:25 |
Anonymous (not verified) |
94.188.205.175 |
Bio-Inspired Design Aeronautics Corp |
6843 Still Creek Pass |
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. |
2024-03-08 |
Joseph Mitchell |
aerotech@hush.com |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Hollie Mitchell |
mitchhollie@yahoo.com |
Vice President |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
953 |
2024-04-08 17:35 |
Anonymous (not verified) |
94.188.205.174 |
Bio-Inspired Design Aeronautics Corp |
6843 Still Creek Pass |
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. |
2024-03-08 |
Hollie Mitchell |
mitchhollie@yahoo.com |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Mitchell |
aerotech@hush.com |
President |
Bettendorf |
Iowa |
United States |
Mike Minnich |
Chris DeCock |
Signed |
954 |
2024-04-08 17:38 |
Anonymous (not verified) |
94.188.205.168 |
Bio-Inspired Design Aeronautics Corp |
6843 Still Creek Pass |
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. |
2024-03-08 |
Hailey Mitchell |
hailey8.hm@hush.com |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Mitchell |
aerotech@hush.com |
President |
Bettendorf |
Iowa |
United States |
Mike Minnich |
Chris DeCock |
Signed |
961 |
2024-04-25 13:08 |
Anonymous (not verified) |
94.188.207.227 |
PROEFCO LLC |
502 South Cadwell Avenue |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-25 |
Kendy Melendrez Figueroa |
Kendydej@gmail.com |
Eagle Grove |
IA |
United States |
Kendy M Figueroa |
Kendy M Figueroa |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kendy M Figueroa |
Kendydej@gmail.com |
Owner |
Eagle Grove |
IA |
United States |
Kendy M Figueroa |
Kendy M Figueroa |
Signed |
971 |
2024-05-03 07:33 |
Anonymous (not verified) |
94.188.205.176 |
Outdoor Pros LLC |
6535 WAPSI AVE SE Lone Tree IA 52755 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-02 |
Erik Alberhasky |
erikalberhas@gmail.com |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik Alberhasky |
erikalberhas@gmail.com |
Owner |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
972 |
2024-05-03 07:35 |
Anonymous (not verified) |
94.188.205.175 |
Outdoor Pros LLC |
6535 WAPSI AVE SE Lone Tree IA 52755 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-02 |
Erik Alberhasky |
erikalberhas@gmail.com |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik Alberhasky |
erikalberhas@gmail.com |
Owner |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
974 |
2024-05-06 08:02 |
Anonymous (not verified) |
94.188.205.176 |
Milton Recycling & Roll Off Service LLC |
1266 218 PL, Boone, IA 50036 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-06 |
Glenn Kreuder |
kreuderfarms@yahoo.com |
Boone |
IA |
United States |
Amanda Krull |
Adam Krull |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Glenn Kreuder |
kreuderfarms@yahoo.com |
Member |
Boone |
IA |
United States |
Amanda Krull |
Adam Krull |
Signed |
977 |
2024-05-08 11:12 |
Anonymous (not verified) |
94.188.207.230 |
JPZ Logistics LLC |
945 Elm St, Naperville, IL 60540 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-08 |
John Loren Polk II |
jpolk@polksolutions.com |
Coralville |
Johnson |
Iowa |
Nicholas Dedio |
Ric Mills |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Loren Polk |
jpolk@polksolutions.com |
owner |
Coralville |
Iowa |
United States |
Ric Mills |
Nicholas Dedio |
Signed |
980 |
2024-05-10 14:51 |
Anonymous (not verified) |
94.188.205.176 |
Access Door Automation |
19068 Mynster Springs Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-10 |
Marshall Miller |
millermarshallt@outlook.com |
council bluffs |
Iowa |
United States |
Kylee Miller |
Ivy Miller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marshall Miller |
millermarshallt@outlook.com |
owner |
council bluffs |
Iowa |
United States |
Kylee Miller |
Ivy Miller |
Signed |
991 |
2024-05-16 11:50 |
Anonymous (not verified) |
94.188.207.229 |
NSG, LLC |
2935 Highway 18, Dickens, IA 51333 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-16 |
Rosemary G Norgaard |
rosemary@norgaardllc.com |
Dickens |
Clay |
United States |
Dan Claus |
Ange Claus |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rosemary G Norgaard |
rosemary@norgaardllc.com |
MEMBER |
Dickens |
Clay |
United States |
Dan Claus |
Ange Claus |
Signed |
208 |
2021-03-16 16:19 |
Anonymous (not verified) |
204.155.61.217 |
AGSPIRE INC |
1310 Kathryn Ct Buffalo, MN 55313 |
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. |
2021-02-02 |
Kent Kiebelkorn |
kent@hailmayday.com |
Buffalo |
Wright County |
Minnesota |
Docusign |
Docusign |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
unknown |
akraft@millerhartwig.com |
Unknown |
unknown |
unknown |
unknown |
unknown |
unknown |
Signed |
805 |
2023-10-31 14:53 |
Anonymous (not verified) |
94.188.207.225 |
PJ Trucking Unlimited LLC |
2617 380th Ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-31 |
Peggy Jensen |
pegandhalj@gmail.com |
Farragut |
Fremont |
Iowa |
Julie Marshall |
Darlene Carpenter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Peggy Jensen |
pegandhalj@gmail.com |
Member |
Farragut |
US |
US |
Julie Marshall |
Darlene Carpenter |
Signed |
40 |
2020-02-14 09:22 |
Anonymous (not verified) |
50.83.38.221 |
Pa's Construction LLC |
2350 Glass RD NE |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-14 |
Daniel Saunders |
dan2112411@yahoo.com |
Cedar Rapids |
USA_IA |
USA_IA |
Walt Cheney |
Becky Cheney |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Saunders |
dan2112411@yahoo.com |
Owner- Manager |
Cedar Rapids |
USA_IA |
USA_IA |
Walt Cheney |
Becky Cheney |
Signed |
444 |
2022-04-14 15:50 |
Anonymous (not verified) |
72.10.21.42 |
Babcock Services Idaho, Inc. |
8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-14 |
Carmen Clyde |
CCLYDE@BABCOCKSERVICES.COM |
KENNEWICK |
WA |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CARMEN CLYDE |
CCLYDE@BABCOCKSERVICES.COM |
Secretary |
KENNEWICK |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
445 |
2022-04-14 15:52 |
Anonymous (not verified) |
72.10.21.42 |
Babcock Services Idaho, Inc. |
8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-14 |
Keith Myers |
CCLYDE@BABCOCKSERVICES.COM |
KENNEWICK |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CARMEN CLYDE |
CCLYDE@BABCOCKSERVICES.COM |
Secretary |
KENNEWICK |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
446 |
2022-04-14 15:54 |
Anonymous (not verified) |
72.10.21.42 |
Babcock Services Idaho, Inc. |
8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-14 |
Phil Gallagher |
pgallagher@babcockservices.com |
Richland |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CARMEN CLYDE |
CCLYDE@BABCOCKSERVICES.COM |
Secretary |
KENNEWICK |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
497 |
2022-06-16 11:09 |
Anonymous (not verified) |
72.10.21.42 |
Babcock Services Idaho, Inc. |
8113 W QUINAULT AVENUE 201, KENNEWICK, WA 99336 |
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. |
2022-06-01 |
WALLACE KENNEDY |
wkennedy@babcockservices.com |
Richland |
Benton |
Washington |
Angie Jimenez |
Karen Patterson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carmen Clyde |
cclyde@babcockservices.com |
Secretary |
Kennewick |
Benton |
Washington |
Angie Jimenez |
Karen Patterson |
Signed |
480 |
2022-05-30 11:37 |
Anonymous (not verified) |
134.215.6.237 |
Access Property Management Corp DBA Wine & Spirits |
510 E Carrington Ln, Appleton, WI 54913 |
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. |
2022-05-30 |
Lisa M Ricklefs |
lisarick19@yahoo.com |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Thomas Ricklefs |
tjrick@yahoo.com |
President |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferak |
Signed |
481 |
2022-05-30 11:42 |
Anonymous (not verified) |
134.215.6.237 |
Access Property Management Corp DBA Wine & Spirits |
510 E Carrington Ln, Appleton, WI 54913 |
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. |
2022-05-30 |
Thomas J Ricklefs |
tjrick@yahoo.com |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa M Ricklefs |
lisarick19@yahoo.com |
VP |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
719 |
2023-07-31 16:00 |
Anonymous (not verified) |
94.188.205.175 |
Krupa-1 LLC |
128 Main 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. |
2023-07-31 |
Maher Patel |
deckerhotel008@gmail.com |
Dodgeville |
Iowa |
WI |
Mitch Schaller |
Susan Cox |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Mihir Patel |
deckerhotel008@gmail.com |
Owner/ Partner |
Fitchberg |
Dane |
WI |
Susan Cox |
Mitch Schaller |
Signed |
720 |
2023-07-31 16:01 |
Anonymous (not verified) |
94.188.205.167 |
Krupa-1 LLC |
128 Main 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. |
2023-07-31 |
Maher Patel |
deckerhotel008@gmail.com |
Dodgeville |
Iowa |
WI |
Mitch Schaller |
Susan Cox |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Mihir Patel |
deckerhotel008@gmail.com |
Owner/ Partner |
Fitchberg |
Dane |
WI |
Susan Cox |
Mitch Schaller |
Signed |
117 |
2020-09-11 11:54 |
Anonymous (not verified) |
162.218.1.22 |
american business resource corporation |
4600 American Parkway Suite #301 Madison, WI 53718 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-11 |
Michelle Szabrowicz |
mszabrowicz@abrjobs.com |
Madison |
Dane |
Wisconsin |
Patricia Haggerty |
Britney Mollet |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michelle Szabrowicz |
mszabrowicz@abrjobs.com |
CFO |
Madison |
Dane |
Wisconsin |
Patricia Haggerty |
Britney Mollet |
Signed |