966 |
2024-04-30 14:39 |
Anonymous (not verified) |
94.188.207.230 |
Bowman Dozing & Excavating LLC |
218 134th ave Maquoketa, IA 52060 |
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. |
2024-04-30 |
Bradley D Bowman |
dozermann9@hotmail.com |
Maquoketa |
Jackson |
Iowa |
Jennifer Machande |
Mitchell Schaller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley D Bowmann |
dozermann9@hotmail.com |
owner/president |
maquoketa |
Jackson |
iowa |
Jennifer Machande |
Mitch Schaller |
Signed |
967 |
2024-05-01 06:30 |
Anonymous (not verified) |
94.188.207.224 |
Cael Gulrud |
206 W Main St Calmar, IA, 52132 |
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. |
2024-05-01 |
Brandon Gulrud |
mojopants21@gmail.com |
Waterloo |
Blackhawk |
IA |
Victoria Bacon-Ortiz |
David Gulrud |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cael Gulrud |
gulrud8728@gmail.com |
Owner |
Calmar |
Winneshiek |
IA |
Victoria Bacon-Ortiz |
David Gulrud |
Signed |
968 |
2024-05-02 13:34 |
Anonymous (not verified) |
94.188.207.227 |
Harman Construction, LLC |
103 NW 6TH ST, POCAHONTAS, IA 50574 |
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 |
DRAKE HARMAN |
harmanconstructionllc@gmail.com |
POCAHONTAS |
POCAHONTAS |
IOWA |
JESSE NEWGARD |
TRACY GROTHAUS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
DRAKE HARMAN |
harmanconstructionllc@gmail.com |
OWNER |
POCAHONTAS |
POCAHONTAS |
IOWA |
JESSE NEWGARD |
TRACY GROTHAUS |
Signed |
969 |
2024-05-02 16:15 |
Anonymous (not verified) |
94.188.205.175 |
Adamantine Spine Moving |
2726 Independence Rd Iowa City, IA 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-02 |
John Clifford Wallace |
cliff.wallace@spinemoving.com |
Des Moines |
Polk |
Iowa |
John Thomas Wallace |
Amanda Root Wallace |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill Hoke |
bill.hoke@spinemoving.com |
HR |
Des Moines |
Polk |
County |
Sarah Mannix |
Erika Banks |
Signed |
970 |
2024-05-02 16:15 |
Anonymous (not verified) |
94.188.205.167 |
Adamantine Spine Moving |
2726 Independence Rd., Iowa City, IA 52240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-02 |
Emily Wallace |
emily.wallace@spinemoving.com |
Des Moines |
Polk |
Iowa |
Margaret Walter |
Dan Walter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William Hoke |
bill.hoke@spinemoving.com |
Owner |
Iowa City |
Johnson |
Iowa |
Sarah Mannix |
Erika Banks |
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 |
973 |
2024-05-03 11:24 |
Anonymous (not verified) |
94.188.207.227 |
Trent Hatlen |
1042 490th Street, Rembrandt, IA 50576 |
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. |
2024-05-03 |
Trent Hatlen |
trentgotti@yahoo.com |
Rembrandt |
Buena Vista |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Trent Hatlen |
trentgotti@yahoo.com |
Owner |
Rembrandt |
Buena Vista |
Iowa |
Jared Brashears |
Katie Gunkelman |
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 |
975 |
2024-05-06 14:30 |
Anonymous (not verified) |
94.188.207.228 |
Plendl Farm Mangement LLC |
4951 Harrison Ave, Maurice, IA 51036 |
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 |
Christopher Plendl |
mcplendl@mtcnet.net |
Maurice |
Sioux |
IA |
Stacey Paulsen |
Austin Reitz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gerald Van Roekel |
gerald@veinsurance.com |
agent |
Orange City |
Sioux |
IA |
Stacey Paulsen |
Austin Reitz |
Signed |
976 |
2024-05-08 11:00 |
Anonymous (not verified) |
94.188.205.177 |
N MCMANUS ENTERPRISES LLC |
2812 Giles St, WDM IA 50265 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-08 |
NATHAN MCMANUS |
nathan.mcmanus55@gmail.com |
DES MOINES |
POLK |
IA |
TRENA MCCRAINE |
MATT CALE |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
NATHAN MCMANUS |
nathan.mcmanus55@gmail.com |
OWNER |
DES MOINES |
POLK |
IA |
TRENA MCCRAINE |
MATT CALE |
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 |
978 |
2024-05-08 13:47 |
Anonymous (not verified) |
94.188.205.174 |
Meridian Logistics, LLC |
5249 N Park Pl NE, Unit #2060, 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. |
2024-05-07 |
Abigail Matthews |
almsolutions2021@gmail.com |
Chicago |
Cook |
IL |
Gayle Matteson |
Jane Calvert |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Abigail Matthews |
almsolutions2021@gmail.com |
Owner |
Chicago |
Cook |
IL |
Gayle Matteson |
Jane Calvert |
Signed |
979 |
2024-05-10 14:40 |
Anonymous (not verified) |
94.188.207.224 |
Paradigm Group, LLC |
3263 Cumming Road, Cumming IA. 50061 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-10 |
Hunter Brown |
bbpropertymaintenance1@gmail.com |
Ankeny |
Polk County |
Iowa |
Landon Brown |
Ryan Rose |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kelsey Prince |
office@prdgmgroup.com |
Office Manager |
Cumming |
Madison |
Iowa |
Kyle McGinn |
Robin McGinn |
Signed |
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 |
981 |
2024-05-10 15:31 |
Anonymous (not verified) |
94.188.205.168 |
Jacob Thompson DBA Jake Thompson Trucking |
2524 Delta Ave, Bridgewater, IA 50837 |
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 |
Jake Thompson |
jakethompsontrucking@yahoo.com |
Bridgewater |
Adair |
Iowa |
Daniela Scacchi |
Jeff Thompson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jake Thompson |
jakethompsontrucking@yahoo.com |
Self |
Bridgerwater |
Adair |
IA |
Daniela Scacchi |
Jeff Thompson |
Signed |
982 |
2024-05-10 19:06 |
Anonymous (not verified) |
94.188.207.228 |
Revella Salon and Spa |
509 Second St Ida Grove, IA 51445 |
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 |
Bailey Roeder |
roeder428@gmail.com |
Ida Grove |
Ida |
Iowa |
Dalton Hemer |
Fina Roeder |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bailey Roeder |
roeder428@gmail.com |
Myself |
Ida Grove |
Ida |
Iowa |
Dalton Hemer |
Fina Roeder |
Signed |
983 |
2024-05-11 12:27 |
Anonymous (not verified) |
94.188.207.225 |
Aluminum King MFG LTD |
700 E Van Buren St, Mitchell, IA 50461 |
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. |
2024-05-11 |
Jeremy Mostek |
katie@flashingthunder.com |
Mitchell |
Mitchell |
IA |
Kristy Wolfe |
Tami Towne |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tami Towne |
ttowne@ryderinsurance.com |
Agent |
Grand Island |
Hall |
NE |
Kristy Wolfe |
Katherine Mostek |
Signed |
984 |
2024-05-13 11:05 |
Anonymous (not verified) |
94.188.207.224 |
Davis County Fiberglass LLC |
20641 Old Highway 2, Bloomfield IA 52537 |
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. |
2024-05-13 |
Ronald Simmons |
daviscountyfiberglass@gmail.com |
Drakesville |
Davis County |
Iowa |
Lisa Bell |
Lynn Bumsted |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Ronald Simmons |
daviscountyfiberglass@gmail.com |
Owner |
Drakesville |
Davis County |
Iowa |
Lisa Bell |
Lynn Bumsted |
Signed |
985 |
2024-05-13 17:15 |
Anonymous (not verified) |
94.188.207.225 |
Rail and Road Equipment Co |
1797 G50 HWY. St. Charles, IA. 50240 |
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. |
2024-05-13 |
Jeffrey Pontier |
railandroad@myomnotel.com |
St Charles |
Warren |
IA |
Abbi Goering |
Travis Allen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey Pontier |
railandroad@myomnitel.com |
President |
St Charles |
Warren |
IA |
Abbi Goering |
Travis Allen |
Signed |
986 |
2024-05-13 17:26 |
Anonymous (not verified) |
94.188.207.229 |
Rail and Road Equipment Co |
1797 G50 HWY. St. Charles, IA. 50240 |
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. |
2024-05-13 |
Ranae Pontier |
railandroad@myomnitel.com |
St Charles |
Warren |
IA |
Abbi Goering |
Travis Allen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ranae Pontier |
railandroad@myomnitel.com |
Vice President |
St Charles |
Warren |
IA |
Abbi Goering |
Travis Allen |
Signed |
987 |
2024-05-13 17:37 |
Anonymous (not verified) |
94.188.205.175 |
Barona Enterprises, LLC |
1655 Stanbridge Ave., Roseville, MN 55113 |
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. |
2024-05-13 |
Stacey Pittroff-Barona |
staceybarona@aol.com |
Roseville |
Ramsey |
Minnesota |
Isabella Barona |
Robert Barona |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Stacey Pittroff-Barona |
staceybarona@aol.com |
Owner |
Roseville |
Ramsey |
Minnesota |
Isabella Barona |
Robert Barona |
Signed |
988 |
2024-05-14 14:12 |
Anonymous (not verified) |
94.188.205.174 |
Kobliska Plumbing Inc. |
291 Crandall Dr. NE Cedar Rapids, IA 52402 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-14 |
Philip P. Kobliska |
jimfortmann60@gmail.com |
Cedar Rapids |
Linn |
Iowa |
James J. Fortmann |
Ruth Beers |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Philip P. Kobliska |
jimfortmann60@gmail.com |
President |
Cedar Rapids |
Linn |
IA |
James J. Fortmann |
Ruth Beers |
Signed |
989 |
2024-05-14 14:14 |
Anonymous (not verified) |
94.188.205.177 |
Kobliska Plumbing Inc. |
291 Crandall Dr. NE Cedar Rapids, IA 52402 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-14 |
Philip P. Kobliska |
jimfortmann60@gmail.com |
Cedar Rapids |
Linn |
Iowa |
James J. Fortmann |
Ruth Beers |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Philip P. Kobliska |
jimfortmann60@gmail.com |
President |
Cedar Rapids |
Linn |
IA |
James J. Fortmann |
Ruth Beers |
Signed |
990 |
2024-05-15 23:19 |
Anonymous (not verified) |
94.188.205.177 |
The Olam LLC |
2821 S 36th Omaha Nebraska 68105 |
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. |
2024-05-15 |
Carlos Sanchez |
Sjuan944@gmail.com |
Omaha |
United State |
Nebraska |
Juan Sanchez |
Gaspar Sanchez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carlos Sanchez |
theolam587@gmail.com |
Owner |
Omaha |
United State |
Nebraska |
Juan Sanchez |
Gaspar Sanchez |
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 |
992 |
2024-05-17 09:04 |
Anonymous (not verified) |
94.188.207.226 |
DEV Mart Inc |
229 West St Grinnell IA |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-17 |
Rakesh Chaudhari |
grinnellmart@gmail.com |
Muscatine |
Muscatine |
Iowa |
Sam Chaudhari |
Arvind Chaudhari |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rakesh Chaudhari |
grinnellmart@gmail.com |
Owner |
Muscatnine |
Iowa |
Iowa |
Sam Chaudhari |
Arvind Chaudhari |
Signed |
993 |
2024-05-17 13:05 |
Anonymous (not verified) |
94.188.205.176 |
Anacleto Campos Rojas |
7 North Street Hartford, Iowa 50118 |
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. |
2024-05-17 |
Anacleto Campos Rojas |
anacletocampos1@icloud.com |
Hartford |
Warren |
Iowa |
Benjamin Campos Rojas |
Ezequiel Campos Rojas |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Anacleto Campos Rojas |
anacletocampos1@icloud.com |
Owner |
Hartford |
Warren |
Iowa |
Benjamin Campos Rojas |
Ezequiel Campos Rojas |
Signed |