227 |
2021-04-02 09:58 |
Anonymous (not verified) |
207.177.7.191 |
GOETTSCH DISPATCH INC |
200 MAIN ST GALVA, IA 51020 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-15 |
ANDREW GOETTSCH |
andygoettsch@gmail.com |
Galva |
Ida |
Iowa |
Kristy Dewey |
Terri Ullrich |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrew Goettsch |
andygoettsch@gmail.com |
President |
Galva |
Ida |
Iowa |
Kristy Dewey |
Terri Ullrich |
Signed |
228 |
2021-04-05 13:06 |
Anonymous (not verified) |
173.18.193.51 |
Houghton Cedar Township Fire Department |
1135 140th Avenue, Salem, Iowa 52649 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-03 |
Brad Vandenberg |
judy@fullenkampins.com |
Donnellson |
Lee |
Iowa |
Judy Moeller |
Shelby Green |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Vandenberg |
judy@fullenkampins.com |
Board Member |
Salem |
Lee |
Iowa |
Judy Moeller |
Shelby Green |
Signed |
229 |
2021-04-05 13:44 |
Anonymous (not verified) |
173.18.193.51 |
Denmark Sanitary District |
PO Box 141, Denmark, Iowa 52624 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-03 |
Clay Fullenkamp |
judy@fullenkampins.com |
West Point |
Lee |
Iowa |
Judy Moeller |
Brian Stuekerjuergen |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Clay Fullenkamp |
judy@fullenkampins.com |
Board Member |
West Point |
Lee |
Iowa |
judy moeller |
brian stuekerjuergen |
Signed |
230 |
2021-04-06 21:15 |
Anonymous (not verified) |
173.23.145.187 |
Jose J Framing |
5301 SE 24th St. Des Moines IA 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-01-01 |
Jose J. Castillo |
castillojosejonathan7@gmail.com |
Des Moines |
Polk |
United States |
Perla Landaverde Garcia |
Alma Y. Gaytan |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jose J. Castillo |
castillojosejonathan7@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Perla Landaverde Garcia |
Alma Y. Gaytan |
Signed |
232 |
2021-04-12 11:14 |
Anonymous (not verified) |
74.84.91.178 |
Heim Enterprises LLC |
13532 Mueller Parkway, Sherrill, IA 52073 |
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. |
2021-04-01 |
Cory Heim |
corypheim@gmail.com |
Sherrill |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Cory Heim |
corypheim@gmail.com |
owner |
Sherrill |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
233 |
2021-04-13 10:35 |
Anonymous (not verified) |
172.83.18.1 |
Skyway Inc |
7030 27th Way, Clear Lake, IA 50428 |
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. |
2021-03-06 |
Brad Thompson |
mary@skywaypropertyinspections.com |
Clear Lake |
Cerro Gordo |
Iowa |
Becky Plagge |
Deb Otto |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Thompson |
mary@skywaypropertyinspections.com |
Owner |
Clear Lake |
Cerro Gordo |
Iowa |
Becky Plagge |
Deb Otto |
Signed |
234 |
2021-04-13 10:37 |
Anonymous (not verified) |
172.83.18.1 |
Skyway Inc |
7030 27th Way, Clear Lake, IA 50428 |
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. |
2021-03-06 |
Mary Thompson |
mary@skywaypropertyinspections.com |
Clear Lake |
Cerro Gordo |
Iowa |
Becky Plagge |
Deb Otto |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Thompson |
mary@skywaypropertyinspections.com |
Owner |
Clear Lake |
Cerro Gordo |
Iowa |
Becky Plagge |
Deb Otto |
Signed |
237 |
2021-04-14 15:00 |
Anonymous (not verified) |
75.89.76.245 |
Pillar Inc. |
906 W. 18th Street, Bldg A, Nevada, Iowa 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 |
Matthew Paul Klucas |
matt@pillariowa.com |
Fort Dodge |
Webster County |
Iowa |
Wendy Bergeson |
Riley Abel |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Matthew Paul Klucas |
matt@pillariowa.com |
Owner |
Fort Dodge |
Webster County |
Iowa |
Wendy Bergeson |
Riley Abel |
Signed |
238 |
2021-04-16 08:25 |
Anonymous (not verified) |
66.43.227.177 |
Zern Farm Corp |
15109 330th St. Conrad, IA 50621 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-03 |
Jack Zern |
nicole.stone@gnbins.com |
Conrad |
Grundy |
Iowa |
Nicole Stone |
Jeff Beeghly |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jack Zern |
nicole.stone@gnbins.com |
President |
Conrad |
Grundy |
Iowa |
Nicole Stone |
Jeff Beeghly |
Signed |
239 |
2021-04-16 08:28 |
Anonymous (not verified) |
66.43.227.177 |
Zern Farm Corp |
15109 330th St. Conrad, IA 50621 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-03 |
Danice Zern |
nicole.stone@gnbins.com |
Conrad |
Grundy |
Iowa |
Nicole Stone |
Jeff Beeghly |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Danice Zern |
nicole.stone@gnbins.com |
Treasurer |
Conrad |
Grundy |
Iowa |
Nicole Stone |
Jeff Beeghly |
Signed |
240 |
2021-04-16 08:30 |
Anonymous (not verified) |
66.43.227.177 |
Zern Farm Corp |
15109 330th St. Conrad, IA 50621 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-03 |
Cloris Zern |
nicole.stone@gnbins.com |
Conrad |
Grundy |
Iowa |
Nicole Stone |
Jeff Beeghly |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cloris Zern |
nicole.stone@gnbins.com |
Secretary |
Conrad |
Grundy |
Iowa |
Nicole Stone |
Jeff Beeghly |
Signed |
241 |
2021-04-16 09:14 |
Anonymous (not verified) |
75.89.76.245 |
PIllar Inc |
906 W 18th 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. |
2021-04-16 |
Jordan Watkins |
jordan@pillariowa.com |
Altoona |
IA |
United States |
Beth May |
jesse backstrom |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Matt Klucas |
matt@pillariowa.com |
VP |
Ft Dodge |
Webster |
Iowa |
Beth May |
Jesse Backstrom |
Signed |
244 |
2021-04-21 15:01 |
Anonymous (not verified) |
63.152.5.170 |
Berghuis Trucking Inc. |
14526 U Ave Ackley Iowa 50601 |
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 |
Justin Berghuis |
justinberghuis@gmail.com |
Ackley |
Hardin |
Iowa |
Thomas Beving |
Lindsey Beving |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Justin Berghuis |
justinberghuis@gmail.com |
owner |
Ackley |
Hardin |
Iowa |
Thomas Beving |
Lindsey Beving |
Signed |
245 |
2021-04-22 10:54 |
Anonymous (not verified) |
172.83.18.1 |
Skyway Inc |
7030 27th Way, Clear Lake, IA 50428 |
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. |
2021-04-22 |
Brad Thompson |
becky@fgains.com |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Thompson |
becky@fgains.com |
Owner |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |
246 |
2021-04-22 10:56 |
Anonymous (not verified) |
172.83.18.1 |
Skyway Inc |
7030 27th Way, Clear Lake, IA 50428 |
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. |
2021-04-22 |
Mary Thompson |
becky@fgains.com |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Thompson |
becky@fgains.com |
Owner |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |
250 |
2021-05-04 10:19 |
Anonymous (not verified) |
216.81.153.249 |
K Drey Ag LLC |
2242 Hope Ave, Early, IA 0535 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-04 |
Kennedy Drey |
kdreyag@gmail.com |
Early |
Sac |
Iowa |
Jared Brashears |
Mary Jo Olthoff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kennedy Drey |
kdreyag@gmail.com |
Owner |
Early |
Sac |
Iowa |
Jared Brashears |
Mary Jo Olthoff |
Signed |
254 |
2021-05-04 17:25 |
Anonymous (not verified) |
208.38.228.16 |
NSENSE Incorporater |
415 Stanton Ave, Suite 205, Ames, IA 50014 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-04 |
Natalia Rogovska |
nrogovska@n-sense.us |
Ames |
Story |
Iowa |
Halyna Mudryk |
Petro Kyveryga |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Natalia Rogovska |
nrogovska@n-sense.us |
Vice-President |
Ames |
Story |
Iowa |
Halyna Mudryk |
Petro Kyveryga |
Signed |
255 |
2021-05-04 21:04 |
Anonymous (not verified) |
208.38.228.16 |
NSENSE Incorporated |
415 Stanton Ave, Suite 205, Ames, IA 50014 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-04 |
Natalia Rogovska |
nrogovska@n-sense.us |
Ames |
Story |
Iowa |
Petro Kyveryga |
Halyna Mudryk |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Natalia Rogovska |
nrogovska@n-sense.us |
Vice-President |
Ames |
Story |
Iowa |
Petro Kyveryga |
Halyna Mudryk |
Signed |
256 |
2021-05-05 08:04 |
Anonymous (not verified) |
206.127.178.33 |
NSense, Inc. |
415 Stanton Ave Suite 205, Ames, IA 50014 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-05 |
Stephen R Ringlee |
sringlee@n-sense.us |
Ames |
Story |
Iowa |
Constance J. Ringlee |
Robert Anders |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Stephen R Ringlee |
sringlee@n-sense.us |
Director |
Ames |
Story |
Iowa |
Constance J Ringlee |
Robert Anders |
Signed |
264 |
2021-05-18 22:36 |
Anonymous (not verified) |
174.71.14.68 |
Town and country Aqua Club |
22687 James Dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-18 |
Hope LaShea Diercks |
townandcountrycb@gmail.com |
Council bluffs |
Pottawattamie |
Iowa |
John James Diercks |
Keenan James Diercks |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Hope LaShea Diercks |
townandcountrycb@gmail.com |
Treasurer |
Council bluffs |
Pottawattamie |
Iowa |
John James Diercks |
Keenan James Diercks |
Signed |
265 |
2021-05-22 13:33 |
Anonymous (not verified) |
75.162.162.238 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave. Apt. 49 Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-22 |
Luz Maria Morales Gutierrez |
lm3673719@gmial.com |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Luz Maria Morales Gutierrez |
lm3673719@gmial.com |
Owner |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
266 |
2021-05-22 13:38 |
Anonymous (not verified) |
75.162.162.238 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave. Apt. 49 Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-22 |
Elmer Lopez Montufar |
lm3673719@gmial.com |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Superior Painting and Remodeling Corp |
lm3673719@gmial.com |
Owner |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
268 |
2021-05-25 10:03 |
Anonymous (not verified) |
174.198.97.100 |
Paradigm Construction, LLC |
960 Pelican Dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-25 |
Joshua Beougher |
jbooyah84@gmail.com |
Winterset |
Madison |
Iowa |
Ryan Shabino |
Jonathon Curtis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ryan Shabino |
ryan@prdgmconstruction.com |
Owner |
Polk City |
Polk |
Iowa |
Josh Beougher |
Jonathon Curtis |
Signed |
270 |
2021-06-01 15:39 |
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. |
2021-05-21 |
Lisa Sieren |
TCSFAB@NETINS.NET |
Keswick |
Keokuk |
Iowa |
Scott Grimm |
Amber Kephart |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Sieren |
TCSFAB@NETINS.NET |
President |
Keswick |
Keokuk |
Iowa |
Scott Grimm |
Amber Kephart |
Signed |
271 |
2021-06-01 15:39 |
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. |
2021-05-21 |
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 |
Keokuk |
Iowa |
Scott Grimm |
Amber Kephart |
Signed |
274 |
2021-06-14 08:34 |
Anonymous (not verified) |
207.191.207.6 |
Total Health Rehabilitation PC |
4332 Pioneer Tr SE, Cedar Rapids, IA 52403 |
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. |
2021-06-14 |
Suzanne E. Cooper |
tcc@acterragroup.net |
Cedar Rapids |
Linn |
Iowa |
Tad C Cooper |
Hallie S Cooper |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Suzanne E. Cooper |
tcc@acterragroup.net |
President |
Cedar Rapids |
Linn |
Iowa |
Tad C Cooper |
Hallie S Cooper |
Signed |
275 |
2021-06-15 13:23 |
Anonymous (not verified) |
172.98.131.84 |
JAVIER CONSTRUCTION INC |
2503 Canyon St SW Cedar Rapids, IA 52404 |
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. |
2021-06-15 |
Javier Adana |
Javierconstruction88@gmail.com |
CEDAR RAPIDS |
LINN |
IOWA |
JASON SCHICK |
LADONNA SCHICK |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
JASON SCHICK |
JASONSCHICK@NEIGHBORINSURANCE.COM |
INSURANCE AGENT |
CEDAR RAPIDS |
LINN |
IOWA |
JASON SCHICK |
LADONNA SCHICK |
Signed |
276 |
2021-06-17 16:00 |
Anonymous (not verified) |
204.155.61.217 |
Gentle Bend Inc |
1075 120th Street Wellman, IA 52356 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-17 |
Greg Gent |
gentagincorporated@gmail.com |
Wellman |
Washington |
Iowa |
Jeff Spenner |
Shawn Powell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Greg Gent |
gentagincorporated@gmail.com |
Owner |
Wellman |
Washington |
Iowa |
Jeff Spenner |
Shawn Powell |
Signed |
278 |
2021-06-18 11:37 |
Anonymous (not verified) |
75.162.29.203 |
Digital Agronomy, LLC |
4270 199th St. Ames, IA 50014 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-06-17 |
Patrick T. Murphy |
ptmurphy82@gmail.com |
Ames |
Story |
Iowa |
David Cory |
Mary Cory |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Patrick T. Murphy |
ptmurphy82@gmail.com |
Owner |
Ames |
Story |
Iowa |
David Cory |
Mary Cory |
Signed |
279 |
2021-06-23 10:41 |
Anonymous (not verified) |
184.80.177.137 |
AA Breeders |
P.O. Box 470 - Epworth, IA 52045 |
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. |
2021-06-22 |
Justin Curtis |
jheims@english-insurance.com |
Epworth |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
AA Breeders - Justin Curtis |
jheims@english-insurance.com |
self |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
280 |
2021-06-29 16:51 |
Anonymous (not verified) |
50.83.167.103 |
King Kleen LLC |
421 S. 6th Street, Burlington, IA 52601 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-29 |
Heidi King |
Kingbizsol@gmail.com |
Burlington |
Des Moines |
Iowa |
Ethan King |
Bob King |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Heidi King |
ethan@kingkleen.biz |
Owner |
Burlington |
Des Moines |
Iowa |
Ethan King |
Robert King |
Signed |
283 |
2021-06-30 14:24 |
Anonymous (not verified) |
75.162.212.130 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave Apt 49 Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-30 |
Luz Maria Morales Gutierrez |
lm3673719@gmail.com |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Luz Maria Morales Gutierrez |
lm3673719@gmail.com |
Owner |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
284 |
2021-06-30 14:27 |
Anonymous (not verified) |
75.162.212.130 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave Apt 49 Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-30 |
Elmer Lopes Montufar |
lm3673719@gmail.com |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Superior Painting and Remodeling Corp |
lm3673719@gmail.com |
Owner |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
285 |
2021-06-30 14:33 |
Anonymous (not verified) |
75.162.212.130 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave Apt 49 Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-30 |
Luz Maria Morales Gutierrez |
lm3673719@gmail.com |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Superior Painting and Remodeling Corp |
lm3673719@gmail.com |
Owner |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
287 |
2021-07-19 11:58 |
Anonymous (not verified) |
207.199.222.199 |
STEPHEN MEMORIAL ANIMAL SHELTER INC |
1716 Pella Ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-26 |
Jeanie Bieri |
jeanie.bieri@musco.com |
Oskaloosa |
Mahaska |
Iowa |
Billy Blake |
Merri Chris Hawker |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeanie Bieri |
jeanie.bieri@musco.com |
Board President |
Oskaloosa |
Mahaska |
Iowa |
Billy Blake |
Merri Chris Hawker |
Signed |
289 |
2021-07-22 17:47 |
Anonymous (not verified) |
172.58.83.5 |
Javier Construction INC |
2503 canyon st sw Cedar Rapids,iowa 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-22 |
Javier Aldana Fuentes |
Javierconstruction88@gmail.com |
Cedar Rapids |
Linn |
Iowa |
DaZsa Aldana |
Donya Fleetwood |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Javier Aldana Fuentes |
Javierconstruction88@gmail.com |
owner |
Cedar Rapids |
LInn |
Iowa |
DaZsa Aldana |
Donya Fleetwood |
Signed |
291 |
2021-07-26 12:31 |
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. |
2021-08-01 |
Chad Chyma |
Chymamenwelding@windstream.net |
Toledo |
Tama |
Iowa |
Matt Zmolek |
Michaela Chyma |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chad Chyma |
Chymamenwelding@windstream.net |
Director |
Toledo |
Tama |
Iowa |
Matt Zmolek |
Michaela Chyma |
Signed |
292 |
2021-07-26 12:38 |
Anonymous (not verified) |
208.95.1.97 |
Chyma's Machine and Welding Shop, 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 |
Iowa |
Matt Zmolek |
Michaela Chyma |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chad Chyma |
Chymamenwelding@windstream.net |
Director |
Toledo |
Tama |
Iowa |
Matt Zmolek |
Michaela Chyma |
Signed |
294 |
2021-07-27 14:10 |
Anonymous (not verified) |
173.19.179.111 |
MILFORD MECHANICAL INC |
1607 L AVE MILFORD, IA 51351 |
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. |
2021-06-14 |
DUSITN BOER |
joel@walkerinsuranceia.com |
MILFORD |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
DUSTIN BOER |
joel@walkerinsuranceia.com |
PRESIDENT |
MILFORD |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
295 |
2021-07-27 15:13 |
Anonymous (not verified) |
75.162.64.21 |
Homars Concrete Inc. |
2439 se 19th st Des Moines IA 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-16 |
Omar Sacramento |
yasiel558@gmail.com |
Des Moines |
Polk |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Omar Sacramento |
yasiel558@gmail.com |
owner |
Des Moines |
polk |
iowa |
liliana sanchez |
yolanda mendoza |
Signed |
299 |
2021-08-02 10:55 |
Anonymous (not verified) |
97.125.35.240 |
L:ion BUilder Construction,, INC |
1705 E 32nd St 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. |
2021-07-24 |
Carlos E Mondoza-Gutierrez |
gutierrezce1992@icloud.com |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Juana M.R. |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carlos E Mendoz-Gutierrez |
gutierrezce1992@icloud.com |
self |
Des Moines |
Polk |
Iowa |
Juan M. R. |
Debra Stratton |
Signed |
301 |
2021-08-04 10:05 |
Anonymous (not verified) |
63.142.48.170 |
Vision Homes Inc |
2566 Ivanhoe Rd. SW Cedar Rapids, IA 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-02 |
DeeAnn Nejdl |
chucknejdl@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Melanie Heitman |
Dan Lillis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
DeeAnn Nejdl |
chucknejdl@gmail.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Melanie Heitman |
Dan Lillis |
Signed |
302 |
2021-08-04 10:08 |
Anonymous (not verified) |
63.142.48.170 |
Vision Homes Inc |
2566 Ivanhoe Rd. SW Cedar Rapids, IA 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-02 |
Charles Nejdl |
chucknejdl@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Melanie Heitman |
Dan Lillis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Charles Nejdl |
chucknejdl@gmail.com |
Vice President |
Cedar Rapids |
Linn |
Iowa |
Melanie Heitman |
Dan Lillis |
Signed |
305 |
2021-08-08 17:02 |
Anonymous (not verified) |
24.119.190.239 |
Shawn Smalls Painting Inc |
2736 South Cedar Street, Sioux City, IA 51106 |
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. |
2021-08-08 |
David Shawn Small |
smallspaintingsc@gmail.com |
Sioux City |
Woodbury |
Iowa |
Douglas Wiliam Ball |
Ruth Elaine Ball |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Shawn Small |
smallspaintingsc@gmail.com |
Owner |
SIoux City |
Woodbury |
Iowa |
Douglas William Ball |
Ruth Elaine Ball |
Signed |
312 |
2021-08-18 22:29 |
Anonymous (not verified) |
166.181.81.19 |
Basset Express Inc. |
1572 Underwood Ave. |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-18 |
Jay R Chelf |
bassetexpress@yahoo.com |
Muscatine |
Muscatine |
IA |
Bill Petersen |
Jody L Young |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Patricia Ann Chelf |
bassetexpress@gmail.com |
President |
Muscatine |
Muscatine |
Iowa |
Bill Petersen |
Jody L Young |
Signed |
319 |
2021-08-24 10:19 |
Anonymous (not verified) |
174.243.114.142 |
Sabbatical Services LLC |
20732 Johnson St., Milo, IA 50166 |
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. |
2021-08-24 |
Bryce Gilbert |
bryce.ssllc@outlook.com |
Milo |
Warren |
Iowa |
Kathryn Gilbert |
Kolton Gilbert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bryce Gilbert |
bryce.ssllc@outlook.com |
President |
Milo |
Warren |
Iowa |
Kathryn Gilbert |
Kolton Gilbert |
Signed |
320 |
2021-08-24 10:49 |
Anonymous (not verified) |
67.55.159.231 |
DL Johnson Company |
48600 Highway 64 Miles, IA 52064 |
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. |
2020-08-24 |
David Lee Johnson |
djohnson7_8@hotmail.com |
Miles |
Jackson |
Iowa |
Jeremy Sullivan |
Mitch Crockett |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Johnson |
Djohnson7_8@hotmail.com |
owner/manager |
Miles |
Jackson |
Iowa |
Jeremy Sullivan |
Mitch Crockett |
Signed |
325 |
2021-09-03 12:50 |
Anonymous (not verified) |
173.19.58.159 |
Oskaloosa Entertainment Inc. |
507 High Ave W Oskaloosa, IA 52577 |
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. |
2021-08-11 |
Minesh Patel |
djraj007@gmail.com |
Oskaloosa |
Mahaska |
Iowa |
Joe Mauro |
Randy Mauro |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Joe Mauro |
joe@mauroinsurance.net |
insurance agent |
DES MOINES |
Polk |
Iowa |
Joe Mauro |
Randy Mauro |
Signed |
328 |
2021-09-08 08:31 |
Anonymous (not verified) |
97.125.157.23 |
Dan Petersen Construction |
1725 S 14th St, Polk City, IA 50026 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-08 |
Daniel Petersen |
danpetersenconstruction@gmail.com |
Polk City |
Polk County |
Iowa |
Jim McMurray |
Erik Gramenz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Petersen |
danpetersenconstruction@gmail.com |
Owner |
Polk City |
Polk |
Iowa |
Jim McMurray |
Erik Gramenz |
Signed |
329 |
2021-09-08 10:18 |
Anonymous (not verified) |
206.80.128.71 |
H F Corporation |
105 E Oskaloosa Pella, IA 50219 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-08 |
Bharat Patel |
super8pella@gmail.com |
Pella |
Marion |
Iowa |
Mark Chambers |
Jim Wessels |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeremy Rogstad |
jeremy@jeremyrogstad.com |
State Farm Agent |
Iowa |
Floyd |
Iowa |
Mark Chambers |
Jim Wessels |
Signed |