28 |
2020-01-07 14:23 |
Anonymous (not verified) |
204.155.62.177 |
Money Handling Machines |
PO Box 34218, Omaha NE 68134-0128 |
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. |
2020-01-01 |
David Jame Grimes |
daveg@moneyhandlingmanchines.com |
Omaha |
Douglas |
Nebraska |
Michael Bowman |
Joy Nickolte |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David James Grimes |
daveg@moneyhandlingmachines.com |
President |
Omaha |
Douglas |
NE |
Michael Bowman |
Joy Nickolite |
Signed |
29 |
2020-01-07 14:24 |
Anonymous (not verified) |
204.155.62.177 |
Money Handling Machines |
PO Box 34218, Omaha NE 68134-0128 |
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. |
2020-01-01 |
Scott Grimes |
daveg@moneyhandlingmanchines.com |
Omaha |
Douglas |
Nebraska |
Michael Bowman |
Joy Nickolte |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David James Grimes |
daveg@moneyhandlingmachines.com |
President |
Omaha |
Douglas |
NE |
Michael Bowman |
Joy Nickolite |
Signed |
30 |
2020-01-07 14:26 |
Anonymous (not verified) |
204.155.62.177 |
Money Handling Machines Inc |
PO Box 34218 , OMaha NE 68134 |
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. |
2020-01-01 |
Scott Grimes |
daveg@moneyhandlingmanchines.com |
Omaha |
Douglas |
Nebraska |
Michael Bowman |
Joy Nickolte |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave Grimes |
daveg@moneyhandlingmachines.com |
President |
Omaha |
Douglas |
NE |
Michael Bowman |
Joy Nickolite |
Signed |
77 |
2020-05-05 16:47 |
Anonymous (not verified) |
173.21.16.121 |
Kevan Oliver Trim Carpentry, Inc. |
2900 Scott Park Road, Eldridge, IA 52748 |
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. |
2020-05-05 |
Kevan Oliver |
kkoliverinc@gmail.com |
Eldridge |
Scott |
Iowa |
Franco Muñoz |
Rolando Muñoz |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Kevan Oliver |
kkoliverinc@gmail.com |
President |
Eldridge |
Scott |
Iowa |
Franco Muñoz |
Rolando Muñoz |
Signed |
78 |
2020-05-05 16:49 |
Anonymous (not verified) |
173.21.16.121 |
Kevan Oliver Trim Carpentry, Inc. |
2900 Scott Park Road, Eldridge, IA 52748 |
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. |
2020-05-05 |
Scarlett Oliver |
scarlettioliver@gmail.com |
Eldridge |
Scott |
Iowa |
Franco Muñoz |
Rolando Muñoz |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Kevan Oliver |
kkoliverinc@gmail.com |
President |
Eldridge |
Scott |
Iowa |
Franco Muñoz |
Rolando Muñoz |
Signed |
103 |
2020-07-23 09:23 |
Anonymous (not verified) |
184.80.177.137 |
Jacob Reiff |
15738 N Cascade Rd - Peosta, IA 52068 |
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. |
2020-07-23 |
Jacob Reiff |
jheims@engish-insurance.com |
Peosta, |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
owner |
Peosta |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
154 |
2021-01-06 13:23 |
Anonymous (not verified) |
167.142.147.6 |
PACIFIC DRYWALL CORPORATION |
105 SNYDER DRIVE HUXLEY, IOWA 50124 |
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. |
2021-01-06 |
LUIS MANUEL AVALOS CASTELANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
DES MOINES |
POLK |
IOWA |
JENNIFER LYNNE ESCOBAR |
JUAN JOSE AVALOS CASTELLANOS |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
LUIS MANUEL AVALOS CASTELANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
PRESIDENT |
DES MOINES |
POLK |
IOWA |
JUAN JOSE AVALOS CASTELLANOS |
JENNIFER LYNNE ESCOBAR |
Signed |
193 |
2021-03-02 11:32 |
Anonymous (not verified) |
50.83.72.164 |
4 corners drywall |
532 w 15 st, Davenport, iowa 52803 |
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. |
2021-03-02 |
Phillip hoxsey |
Phillhoxsey81@gmail.com |
Davenport |
Scott |
Iowa |
Donivan hoxsey |
Connor ruge |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Phillip hoxsey |
Phillhoxsey81@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Donivan hoxsey |
Connor ruge |
Signed |
194 |
2021-03-02 11:42 |
Anonymous (not verified) |
50.83.72.164 |
D’s Drywall |
1217 n Blanchard st |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-03-02 |
Donivan hoxsey |
hdonivan@gmail.com |
Davenport |
Scott |
Iowa |
Phillip hoxsey |
Connor ruge |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Donivan hoxsey |
hdonivan@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Phillip hoxsey |
Connor ruge |
Signed |
204 |
2021-03-08 10:43 |
Anonymous (not verified) |
151.147.196.21 |
Iowa Gold Distributing, Inc. |
600 Iehl Street, Central City, IA 52214 |
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. |
2021-02-10 |
Brad Coates |
igdenv@aol.com |
Central City |
Linn |
Iowa |
William Walters |
Jennifer Leinen |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Brad Coates |
igdenv@aol.com |
Director |
Central City |
Linn |
Iowa |
William Walters |
Jennifer Leinen |
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 |
247 |
2021-04-27 09:35 |
Anonymous (not verified) |
207.191.206.210 |
United windows and siding |
4080 1st Avenue NE, Cedar Rapids Iowa 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. |
(2) I decline to reject the employer’s liability coverage. |
2021-04-27 |
Adrian Sanchez |
adrian@unitedwindowsandsiding.com |
Aurora |
CO |
United States |
Megan Bierley |
Ginger Berens |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Adrian Sanchez |
adrian@unitedwindowsandsiding.com |
Owner |
Aurora |
Jeffereson |
CO |
Megan Bierley |
Ginger Berens |
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 |
332 |
2021-09-13 13:30 |
Anonymous (not verified) |
173.23.250.91 |
Cheri’s roofing |
230 palomino pkwy Des Moines Iowa 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. |
2021-09-13 |
Cheryl Martinez |
cheri6876@yahoo.com |
Des Moines |
Polk |
Iowa |
Cheryl Martinez |
Cheryl martinez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chery Martinez |
cheri6876@yahoo.com |
Owner |
Des Moines |
Polk |
Iowa |
Cheryl Martinez |
Cheryl Martinez |
Signed |
341 |
2021-10-05 13:52 |
Anonymous (not verified) |
98.22.0.231 |
Randall Roofing, Inc. |
1531 Shady Brook Lane, 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. |
(2) I decline to reject the employer’s liability coverage. |
2021-10-10 |
Randall Bernard Jarzombek |
randy@randallroofs.com |
Pella |
Marion |
Iowa |
Mark Densmore |
Erica Clifford |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Randall Bernard Jarzombek |
randy@randallroofs.com |
Owner |
Pella |
Marion |
Iowa |
Mark Densmore |
Erica Clifford |
Signed |
357 |
2021-11-10 11:32 |
Anonymous (not verified) |
207.45.82.37 |
Green and Shine Services. INC |
210 Ne 41st ST APT 203 Ankeny, Iowa 50021 |
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. |
2021-11-10 |
Alex Adanel Lopez Redondo |
greenandshineservices@gmail.com |
Ankeny |
polk |
Iowa |
Marta Casado |
Giselle Roa Casado |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Alex ADANEL Lopez Redondo |
greenandshineservices@gmail.com |
owner |
Ankeny |
polk |
Iowa |
Marta Casado |
Giselle Roa Casado |
Signed |
386 |
2022-01-11 08:30 |
Anonymous (not verified) |
173.29.238.103 |
Brilliant All-Seasons Lighting Inc. |
10357 NW 42nd St., Polk City, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2022-01-11 |
Katrina Marie Loney |
katrinaloney@outlook.com |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Brad Loney |
bloney@live.com |
President |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
468 |
2022-05-12 11:33 |
Anonymous (not verified) |
173.23.25.243 |
RS Remodelers |
2863 104th St Urbandale IA 50322 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2022-05-12 |
Robert Nevitt |
rwnevitt@yahoo.com |
PERRY |
DALLAS |
IA |
Steve Dillon |
Jordan Nevitt |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Robert Nevitt |
clearchoicedesmoinesia@gmail.com |
Owner |
Urbandale |
Dallas |
ia |
Steve Dillon |
Jordan Nevitt |
Signed |
469 |
2022-05-12 11:38 |
Anonymous (not verified) |
173.23.25.243 |
RS- Remodelers |
2863 104th St Urbandale IA 50322 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2022-05-12 |
Stephen Dillon |
clearchoicedesmoinesia@gmail.com |
Waukee |
Dallas |
IA |
Rob Nevitt |
Jordan Nevitt |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Stephen |
clearchoicedesmoinesia@gmail.com |
Owner |
Waukee |
Dallas |
IA |
Rob Nevitt |
Jordan Nevitt |
Signed |
501 |
2022-06-24 12:10 |
Anonymous (not verified) |
173.31.148.43 |
HISTORIC ARNOLDS PARK INC |
37 LAKE ST ARNOLDS PARK, IA 51331 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2022-06-24 |
JON PAUSLEY |
JON@ARNOLDSPARK.COM |
MILFORD |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
JON PAUSLEY |
JON@ARNOLDSPARK.COM |
CEO |
MILFORD |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
539 |
2022-09-22 18:03 |
Anonymous (not verified) |
166.181.87.86 |
Abarrotes La Salud, Inc. |
17 North 1st 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. |
(2) I decline to reject the employer’s liability coverage. |
2022-09-22 |
Gabriela Vargas Avalos |
mtownlasalud@gmail.com |
Marshalltown |
Marshall |
Iowa |
Antonio Ramirez Sanchez |
Genoveva Alvizu Hernandez |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Gabriela Vargas Avalos |
mtownlasalud@gmail.com |
Vice President |
Marshalltown |
Marshall |
Iowa |
Antonio Ramirez Sanchez |
Genoveva Alvizu Hernandez |
Signed |
609 |
2023-02-22 18:56 |
Anonymous (not verified) |
94.188.205.174 |
Roman construction |
3214 se 20th st, Des Moines, Iowa, 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. |
2023-02-22 |
Jonathan roman |
romanconstruction21@outlook.com |
Des moines |
Polk |
Iowa |
Jonathan Roman |
Perla Roman |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jonathan Roman |
romanconstruction21@outlook.com |
Owner |
Des moines |
Polk |
Iowa |
Jonathan roman |
Perla roman |
Signed |
610 |
2023-02-23 16:19 |
Anonymous (not verified) |
94.188.207.228 |
Glorious tile service llc |
3905 NE 6th st Ankeny IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2023-02-23 |
Heileselaisi unguec |
glorioustile6@gmail.com |
Ankeny |
United States |
IOWA |
Robert duku |
Abraham deng |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Heileselaisi unguec |
glorioustile6@gmail.com |
Owner llc member |
Ankeny |
United States |
Iowa |
Robert duku |
Abraham deng |
Signed |
611 |
2023-02-23 16:27 |
Anonymous (not verified) |
94.188.207.224 |
Sandra unguec |
3905 NE 6th st Ankeny IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2023-02-23 |
Sandra unguec |
glorioustile6@gmail.com |
Ankeny |
United States |
Iowa |
Robert duku |
Abraham deng |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Sandra unguec |
glorioustile6@gmail.com |
Wife of the owner |
Ankeny |
United States |
Iowa |
Robert duku |
Abraham deng |
Signed |
615 |
2023-02-28 08:15 |
Anonymous (not verified) |
94.188.207.224 |
River City Transport |
201 Lezlie 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. |
(2) I decline to reject the employer’s liability coverage. |
2023-02-28 |
Christopher Ryan Brewer |
chris@rivercitylogistics.net |
Peosta |
Dubuque County |
Iowa |
Brian Brewer |
Nicholas Lester |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chris Brewer |
chris@rivercitylogistics.net |
Owner |
Peosta |
Iowa |
United States |
Brian Brewer |
Nicholas Lester |
Signed |
659 |
2023-04-21 13:58 |
Anonymous (not verified) |
94.188.205.168 |
Streamline Plumbing LLC |
1513 Nw 8th St Grimes, IA 50111 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2023-04-21 |
Benjamin Molloy |
slplumbing.llc@gmail.com |
Grimes |
IA |
United States |
Christine Darnell |
Steven Perona |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Benjamin Molloy |
slplumbing.llc@gmail.com |
owner |
Grimes |
IA |
United States |
Christine Darnell |
Steven Perona |
Signed |
739 |
2023-08-11 18:02 |
Anonymous (not verified) |
94.188.205.176 |
Frontline Roofing & Construction LLC |
310 W Gilbert 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. |
(2) I decline to reject the employer’s liability coverage. |
2023-08-10 |
Verónica Santos |
FrontlineR-C@outlook.com |
Evansdale |
BlackHawk County |
IA |
Angela Hernandez |
Kevi Hernandez |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Veronica Santos |
angelasermeno@gmail.com |
Owner |
Evansdale |
BlackHawk |
IA |
Angela |
Hernandez |
Signed |
748 |
2023-08-20 14:18 |
Anonymous (not verified) |
94.188.205.177 |
NexLevelMoving |
1186 capital dr sw |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2023-08-16 |
Ethan Daniel Sailer |
ethan.sailer@hscsi.net |
Cedar Rapids |
Linn County |
Iowa |
Denis Sailer |
Penny Sailer |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Tarin Erenberger |
tarin.nexlevelmoving@gmail.com |
Employee |
Cedar Rapids |
Linn County |
Iowa |
Taj Barrett |
Taj Barrett |
Signed |
881 |
2024-02-05 11:08 |
Anonymous (not verified) |
94.188.205.168 |
Nxt Level |
1186 Capital Dr sw |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2024-02-05 |
Robert Sanders |
Sandersrob101300@gnail.com |
cedar rapids |
Linn |
iowa |
n/a |
n/a |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
next level |
nextlevelmoving@gmail.com |
labor |
cedar rapids |
linn |
iowa |
n/a |
n/a |
Signed |
882 |
2024-02-05 11:18 |
Anonymous (not verified) |
94.188.205.175 |
next level moving |
1186 Capital Dr Sw cedar rapids iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2024-02-05 |
Robert Sanders |
sandersrob101300@gmail.con |
cedar rapids |
linn |
iowa |
phoenix sims |
n/a |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
next level moving |
tarin.nexlevelmoving@gmail.com |
labor |
cedar rapids |
linn |
iowa |
n/a |
n/a |
Signed |
946 |
2024-04-04 11:53 |
Anonymous (not verified) |
94.188.205.169 |
Soto Stone LLC |
1071 Mansfield dr waukee iowa 50263 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2024-04-04 |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
Waukee |
DALLAS |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
Self |
Waukee |
Dallas |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
Signed |
957 |
2024-04-15 10:15 |
Anonymous (not verified) |
94.188.207.226 |
Calvillo & Son Construction |
1802 Mondamin Ave, Des Moines, Iowa, 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2024-04-15 |
Gerardo Calvillo |
Joedhsanchez@icloud.com |
Des Moines |
Polk |
Iowa |
Agustín Téllez |
Aurora Maciel Colin |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Gerardo Calvillo |
Joedhsanchez@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Agustín Téllez |
Aurora Maciel Colin |
Signed |
16 |
2019-12-12 13:17 |
Anonymous (not verified) |
65.126.161.162 |
MGF Concrete DBA Michael Frandsen |
3306 66th Avenue Moline, IL 61265 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-12-12 |
Michael Frandsen |
None@none.com |
Moline |
Rock Island |
Illinois |
Sarah Robertson |
Beth Welzenbach |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Frandsen |
None@none.com |
Owner |
Moline |
Rock Ilsand |
Illinois |
Sarah Robertson |
Beth Welzenbach |
Signed |
17 |
2019-12-12 13:20 |
Anonymous (not verified) |
65.126.161.162 |
Robert J Schroeder Const. Inc. |
10984 150th St Davenport, IA 52804 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-12-12 |
Robert J Schroeder |
None@none.com |
Davenport |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert J Schroeder |
None@none.com |
President |
Davenport |
Scott |
Iowa |
Sarah Robertson |
Beth Welzenbach |
Signed |
18 |
2019-12-16 14:00 |
Anonymous (not verified) |
206.80.132.15 |
Cresco Family Dentistry P.C. |
210 N Elm St Cresco, IA 52136 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-12-16 |
Jeffrey K Haw |
cfdentistry@iowatelecom.net |
Cresco |
Howard |
Iowa |
Don Dietzenbach |
Kim Holmes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey K Haw |
cfdentistry@iowatelecom.net |
President |
Cresco |
Howard |
Iowa |
Don Dietzenbach |
Kim Holmes |
Signed |
19 |
2019-12-16 14:04 |
Anonymous (not verified) |
206.80.132.15 |
Cresco Family Dentistry P.C. |
210 N Elm St Cresco, IA 52136 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-12-16 |
Shirlee J Haw |
cfdentistry@iowatelecom.net |
Cresco |
Howard |
Iowa |
Don Dietzenbach |
Kim Holmes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey K Haw |
cfdentistry@iowatelecom.net |
President |
Cresco |
Howard |
Iowa |
Don Dietzenbach |
Kim Holmes |
Signed |
20 |
2019-12-30 09:39 |
Anonymous (not verified) |
207.191.194.182 |
LA Trends Addict Inc |
1200 N CENTER POINT 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. |
2019-10-07 |
Laura Frey |
fcrentals1@gmail.com |
HIAWATHA |
Linn |
IA |
Traci Lyons |
Allie DeVore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Laura Frey |
fcrentals1@gmail.com |
Owner |
HIAWATHA |
Linn |
IA |
Traci Lyons |
Allie DeVore |
Signed |
21 |
2019-12-30 11:28 |
Anonymous (not verified) |
207.191.194.182 |
Bob Stephen Motors Inc |
324 W Main St, Manchester IA 52057 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-11-05 |
Paul Roussell |
twyladetrich@gmail.com |
MANCHESTER |
DELAWARE |
IA |
Traci Lyons |
Allie DeVore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Heidi Roussell |
twyladetrich@gmail.com |
Vice President |
Manchester |
DELAWARE |
IA |
Traci Lyons |
Allie DeVore |
Signed |
22 |
2019-12-30 11:30 |
Anonymous (not verified) |
207.191.194.182 |
Bob Stephen Motors Inc |
324 West Main St, Manchester IA 52057 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-11-05 |
Heidi Roussell |
twyladetrich@gmail.com |
Manchester |
DELAWARE |
IA |
Traci Lyons |
Allie DeVore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Roussell |
twyladetrich@gmail.com |
President |
MANCHESTER |
Delaware |
IA |
Traci Lyons |
Allie DeVore |
Signed |
23 |
2019-12-31 09:01 |
Anonymous (not verified) |
65.126.161.162 |
Shawn Watson DBA SW Painting |
1205 13th Ave Orion, IL 61273 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-12-31 |
Shawn Michael Watson |
None@none.com |
Orion |
Henry |
Illinois |
Sarah Robertson |
Beth Welzenbach |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Shawn Watson |
None@none.com |
Owner |
Orion |
Henry |
Illinois |
Sarah Robertson |
Beth Welzenbach |
Signed |
24 |
2020-01-02 09:12 |
Anonymous (not verified) |
207.191.194.182 |
Waukee CabinetWorks LLC |
70 SE Laurel St, Waukee IA 50263 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-12-23 |
Amy Balm |
chris.rappe@waukeecabinetworks.com |
Waukee |
Dallas |
Iowa |
Chris Andrews |
Dave Creighton Sr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chris Rappe |
chris.rappe@waukeecabinetworks.com |
Operations Manager |
Waukee |
Dallas |
IA |
Chris Andrews |
Dave Creighton SR |
Signed |
25 |
2020-01-02 09:17 |
Anonymous (not verified) |
207.191.194.182 |
Waukee CabinetWorks LLC |
70 SE Laurel St, Waukee IA 50263 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-12-23 |
Jason Balm |
chris.rappe@waukeecabinetworks.com |
Waukee |
Dallas |
Iowa |
Chris Andrews |
Dave Creighton Sr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chris Rappe |
chris.rappe@waukeecabinetworks.com |
Operations Manager |
Waukee |
Dallas |
Iowa |
Chris Andrews |
Dave Creighton SR |
Signed |
26 |
2020-01-07 11:00 |
Anonymous (not verified) |
208.95.1.97 |
Rumours Sports Bar & Grill |
309 N 12th Ave Place Marshalltown IA 50158 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-11-07 |
Jason Priske |
darla.rowley@insurecentraliowa.com |
Marshalltown |
Marshall |
Iowa |
Darla Rowley |
Samantha Garrison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jason Priske |
darla.rowley@insurecentraliowa.com |
Owner |
Marshalltown |
Marshall |
Iowa |
Darla Rowley |
Samantha Garrison |
Signed |
27 |
2020-01-07 11:03 |
Anonymous (not verified) |
208.95.1.97 |
Rumours Sports Bar and Grill |
309 N 12th Avenue Place Marshalltown IA 50158 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-11-07 |
Janet Priske |
darla.rowley@insurecentraliowa.com |
Marshalltown |
Marshall |
Iowa |
Darla Rowley |
Samantha Garrison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Janet Priske |
darla.rowley@insurecentraliowa.com |
Owner |
Marshalltown |
Marshall |
Iowa |
Darla Rowley |
Samantha Garrison |
Signed |
31 |
2020-01-07 14:30 |
Anonymous (not verified) |
204.155.62.177 |
Money Handling Machines Inc |
PO Box 34218 , OMaha NE 68134 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-01-01 |
Mark Grimes |
daveg@moneyhandlingmanchines.com |
Omaha |
Douglas |
Nebraska |
Michael Bowman |
Joy Nickolte |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave Grimes |
daveg@moneyhandlingmachines.com |
President |
Omaha |
Douglas |
NE |
Michael Bowman |
Joy Nickolite |
Signed |
32 |
2020-01-14 10:33 |
Anonymous (not verified) |
108.171.132.189 |
B & C Lawn Care Inc |
P.O. Box 55, 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. |
2020-01-01 |
Travis Garrett |
onethird4599@gmail.com |
Boone |
Boone |
Iowa |
Katie Frame |
Jessica Carroll |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis Garrett |
onethird4599@gmail.com |
Owner |
Boone |
Boone |
IOWA |
Katie Frame |
Jessica Carroll |
Signed |
33 |
2020-01-15 10:31 |
Anonymous (not verified) |
216.161.118.103 |
ELOHIM HOME CARE AND STAFFING AGENCY, INC |
301 NE Trilein Dr , ste 4B, Ankeny IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-01-15 |
NITEZEHO NIYOMUGABO |
john@elohimhcs.com |
Ankeny |
Iowa |
United States |
john Tez |
Sem R |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Tez |
john@elohimhcs.com |
Director |
Ankeny |
IA |
United States |
John Tez |
Tez |
Signed |
34 |
2020-01-16 13:10 |
Anonymous (not verified) |
108.171.132.188 |
B & C Lawn Care Inc |
P.O. Box 55, 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. |
2020-01-01 |
Caleb Elliott |
onethird4599@gmail.com |
Boone |
Boone |
Iowa |
Katie Frame |
Jessica Carroll |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Caleb Elliott |
onethird4599@gmail.com |
Owner |
Boone |
Boone |
IOWA |
Katie Frame |
Jessica Carroll |
Signed |
35 |
2020-01-31 14:56 |
Anonymous (not verified) |
96.31.22.239 |
HOGMILE PORK LLC |
2032 220TH ST INWOOD, IOWA 51240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-01-31 |
GALEN VANDEVEGTE |
galenvv@alliancecom.net |
INWOOD |
LYON |
IOWA |
LISA FABER |
ERIC TEGROOTENHUIS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
GALEN VANDEVEGTE |
galenvv@alliancecom.net |
SELF |
INWOOD |
LYON |
IOWA |
LISA FABER |
ERIC TEGROOTENHUIS |
Signed |
36 |
2020-01-31 14:59 |
Anonymous (not verified) |
96.31.22.239 |
HOGMILE PORK LLC |
2032 220TH ST INWOOD IOWA 51240 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-01-31 |
GLENN VANDEVEGTE |
glenvv@alliancecom.net |
INWOOD |
LYON |
IOWA |
LISA FABER |
ERIC TEGROOTENHUIS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
GLENN VANDEVEGTE |
glennvv@alliancecom.net |
self |
INWOOD |
LYON |
IOWA |
LISA FABER |
ERIC TEGROOTENHUIS |
Signed |