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Rejection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Corporation: Address of Corporation Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Statement Agreement: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Agreement: Alternative Selection: Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Corporation of Authorized Agent: City of Residence: County of Residence: State: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
108 2020-08-19 09:39 Anonymous (not verified) 184.80.177.137 Michelle's Vocational Placement LLC 2642 Farragut Pl., 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. 2020-08-18 Tara Rommel jheims@engish-insurance.com Davenport Scott Iowa Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
320 2021-08-24 10:49 Anonymous (not verified) 67.55.159.231 DL Johnson Company 48600 Highway 64 Miles, IA 52064 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-08-24 David Lee Johnson djohnson7_8@hotmail.com Miles Jackson Iowa Jeremy Sullivan Mitch Crockett Signed (1) The corporation rejects the employers’ liability coverage. David Johnson Djohnson7_8@hotmail.com owner/manager Miles Jackson Iowa Jeremy Sullivan Mitch Crockett Signed
110 2020-08-25 14:31 Anonymous (not verified) 199.241.229.222 Ney Trucking Inc 5070 Wolff Rd Dubuque, IA 52002 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-08-25 Marvin L Ney marvin@paramountems.com Peosta Dubuque Iowa Karen Ludovissy Brenda Weatherwax Signed (1) The corporation rejects the employers’ liability coverage. Maria A Ney maria@paramountems.com Secretary Peosta Dubuque IA Karen Ludovissy Brenda Weatherwax Signed
113 2020-09-03 14:22 Anonymous (not verified) 72.255.74.171 James Raymond and Associates Inc 240 S 1st St, Carlisle, IA 50047 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-03 Jim Downs jdowns@arrowisg.com Carlisle Warren Iowa TJ Cataldo Patti Isley Signed (1) The corporation rejects the employers’ liability coverage. Jim Downs jdowns@arrowisg.com Owner Carlisle Warren Iowa TJ Cataldo Patti Isley Signed
114 2020-09-04 13:11 Anonymous (not verified) 107.182.207.0 KEITH N SLYTER PO 2632 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-04 KEITH N SLYTER KNSCONST@GMAIL.COM DAVENPORT 25|IA iowa KEITH N SLYTER KEITH N SLYTER Signed (1) The corporation rejects the employers’ liability coverage. KEITH N SLYTER KNSCONST@GMAIL.COM owner DAVENPORT 25|IA iowa KEITH N SLYTER KEITH N SLYTER Signed
115 2020-09-08 09:48 Anonymous (not verified) 184.80.177.137 Beyond Builders LLC 206 Culver Road NE, Hopkinton, IA 52237 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-08 John Eiben ginger_bread_man@msn.com HOPKINTON Delaware IA Derrick Parsons Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. John Eiben ginger_bread_man@msn.com Owner Hopkinton Delaware Iowa Derrick Parsons Derrick Parsons Signed
116 2020-09-11 11:42 Anonymous (not verified) 69.57.22.68 Brush and Weed Control Specialists, Inc. 1108 230th Street - Algona, IA 50511 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-11 Ruth Jean Lindgren bwcontrol@netamumail.com Algona Kossuth Iowa James Black Katie Melvin Signed (1) The corporation rejects the employers’ liability coverage. Donald H Reffer bwcontrol@netamumail.com President and General Manager Algona Kossuth Iowa James Black Katie Melvin Signed
117 2020-09-11 11:54 Anonymous (not verified) 162.218.1.22 american business resource corporation 4600 American Parkway Suite #301 Madison, WI 53718 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-11 Michelle Szabrowicz mszabrowicz@abrjobs.com Madison Dane Wisconsin Patricia Haggerty Britney Mollet Signed (1) The corporation rejects the employers’ liability coverage. Michelle Szabrowicz mszabrowicz@abrjobs.com CFO Madison Dane Wisconsin Patricia Haggerty Britney Mollet Signed
118 2020-09-15 14:32 Anonymous (not verified) 174.243.115.133 Jurisdiction Approved Plumbing Corporation P.O. Box 343 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-15 Christian m Lavia eeejumble@gmail.com Urbandale Polk Iowa Tina m Heuckendorf Roslyn Heuckendorf Signed (1) The corporation rejects the employers’ liability coverage. Christian m Lavia eeejumble@gmail.com Director Urbandale Polk IOWA Tina m Heuckendorf Roslyn Heukendorf Signed
119 2020-09-28 10:43 Anonymous (not verified) 174.213.149.6 Ddp construction 1923 63rd st, des moines ,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. (1) I reject the employers’ liability coverage. 2020-09-28 Dustin a perry perrythedustin@gmail.com Urbandale Polk Iowa Lucas jackson Cody roth Signed (1) The corporation rejects the employers’ liability coverage. Smith Kenyon insurance smithkenyon@yahoo.com Agent Urbandale Polk Ia Lucas jackson Cody roth Signed
120 2020-10-01 09:34 Anonymous (not verified) 50.82.176.77 Kinion Towing Inc. 100 Industrial Park Drive, Clarence, IA 52216 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-30 Dale Kinion kinionas@yahoo.com Monmouth Jones Iowa Michael Blake Jeffrey Case Signed (1) The corporation rejects the employers’ liability coverage. Dale Kinion kinionas@yahoo.com President Monmouth Jones Iowa Michael Blake Jeffrey Case Signed
121 2020-10-01 09:40 Anonymous (not verified) 50.82.176.77 Kinion Towing Inc. 100 Industrial Park Drive, Clarence, IA 52216 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-30 Adam Kinion kinionas@yahoo.com Tipton Cedar Iowa Michael Blake Jeffrey Case Signed (1) The corporation rejects the employers’ liability coverage. Adam Kinion kinionas@yahoo.com Vice President Tipton Cedar Iowa Michael Blake Jeffrey Case Signed
122 2020-10-05 15:21 Anonymous (not verified) 173.24.190.134 Greg Haldin Construction, Inc. PO Box 387, Sioux Rapids, IA 50585 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. 2020-10-06 Greg Haldin ghconstruction@live.com Sioux Rapids Buena Vista IA Candie Clark Scott Wirtz Signed (1) The corporation rejects the employers’ liability coverage. Greg Haldin ghconstruction@live.com President Sioux Rapids Buena Vista IA Candie Clark Scott Wirtz Signed
124 2020-10-21 14:07 Anonymous (not verified) 173.23.249.165 Madison County Auction Company LLC 1204 West Summit Winterset, IA 50273 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. 2020-10-09 Tim Gomez tjagomez@gmail.com Winterset Madison Iowa Sheena Earles Russell Boggs Signed (1) The corporation rejects the employers’ liability coverage. Russell Boggs Russell.Boggs@fbfs.com None St Charles madison iowa Sheena Earles Russell Boggs Signed
123 2020-10-20 17:35 Anonymous (not verified) 66.172.250.9 Ladwig Constrution 509 Moorehead 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. 2020-10-20 Ross Ladwig rossladwig@gmail.com Ida Grove Ida Iowa Christine Ladwig Kya Ladwig Signed (2) The corporation declines to reject the employers’ liability coverage. Ross Ladwig rossladwig@gmail.com Owner Ida Grove Ida Iowa Christine Ladwig Kya Ladwig Signed
125 2020-10-26 16:33 Anonymous (not verified) 162.253.44.212 Gutter Filter Specialists Inc 1805 Red Fox Way Marion, IA 52302 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-10-26 Richard L Mellor rickmellor88@gmail.com Marion Linn IA Katie Luehrsmann Melissa Lown Signed (1) The corporation rejects the employers’ liability coverage. Richard L Mellor rickmellor88@gmail.com President Marion Linn IA Katie Luehrsmann Melissa Lown Signed
128 2020-10-29 07:51 Anonymous (not verified) 74.84.91.178 J & J Drywall LLC 1277 Elm Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-10-27 Jeff Frick frickdbq@gmailc.com Dubuque Dubuque IA Brenda Lewis Gabe Drewelow Signed (1) The corporation rejects the employers’ liability coverage. Jeff Frick frickdbq@gmailc.com president Dubuque Dubuque Iowa Brenda Lewis Gabe Drewelow Signed
129 2020-10-30 11:23 Anonymous (not verified) 184.80.177.137 Haberdash Outfitters, Inc. 109 1st Ave East - Dyersville, IA 52040 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. 2020-10-27 Jennifer Recker jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
126 2020-10-28 14:31 Anonymous (not verified) 104.207.25.44 Little Bison Daycare Center 404 2nd St. NW Buffalo Center, IA 50424 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. 2020-10-28 Cody Tyler Wirtjes cody@afschem.com Buffalo Center Winnebago Iowa Michael James Perkins Garrett Alan Asmus Signed (1) The corporation rejects the employers’ liability coverage. Cody Tyler Wirtjes cody@afschem.com Board President Buffalo Center Winnebago Iowa Michael James Perkins Garrett Alan Asmus Signed
127 2020-10-28 14:42 Anonymous (not verified) 104.207.31.201 Little Bison Childcar Center, Inc. 404 2nd St NW 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. 2020-10-28 Travis Brass travis.brass@rakestatesavingsbank.com Lakota Kossuth Iowa Tami Jacobson Carol Winter Signed (1) The corporation rejects the employers’ liability coverage. Travis Brass travis.brass@rakestatesavingsbank.com Treasurer Lakota Kossuth Iowa Tami Jacobson Carol Winter Signed
140 2020-11-25 12:43 Anonymous (not verified) 63.152.43.202 All Heart Staffing, Inc. 4403 1ST AVE. SE, SUITE 310, 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. 2020-11-01 Joel Katcher Joel@AllHeartStaffing.com CEDAR RAPIDS IA United States Andy Becker Kathryn Brown Signed (1) The corporation rejects the employers’ liability coverage. Joel Katcher Joel@AllHeartStaffing.com President CEDAR RAPIDS IA United States Andy Becker Kathryn Brown Signed
130 2020-11-02 12:40 Anonymous (not verified) 67.55.220.86 Little Bison Childcare Center 404 2nd St NW, Buffalo Center, IA 50424 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. 2020-11-02 Joseph Robert Angstman angstman.joe@gmail.com Buffalo Center Winnebago Iowa Emily Jean Thomsen Angstman Pamela Kay Angstman Signed (1) The corporation rejects the employers’ liability coverage. Joseph Robert Angstman angstman.joe@gmail.com Secretary Buffalo Center Winnebago Iowa Emily Jean Thomsen Angstman Pamela Kay Angstman Signed
131 2020-11-03 10:26 Anonymous (not verified) 207.32.1.185 Little Bison Childcare Center 404 2nd ST NW Buffalo Center, IA. 50424 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. 2020-11-03 Megan C Holland megzholland@live.com Buffalo Center Winnebago Iowa Nicholas D Holland Emily J Angstman Signed (1) The corporation rejects the employers’ liability coverage. Megan C Holland megzholland@live.com Vice President Buffalo Center Winnebago Iowa Nicholas D Holland Emily J Angstman Signed
132 2020-11-03 13:22 Anonymous (not verified) 173.22.125.16 BeraTek Industries 407 9th Ave SE, Cedar Rapids, IA 52401 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. 2020-11-03 Ethan Davidson edavidson@beratek-industries.com Cedar Rapids Linn Iowa Raymond Gerald Beranek Ethan Paul Davidson Signed (1) The corporation rejects the employers’ liability coverage. Ethan Paul Davidson edavidson@beratek-industries.com President Cedar Rapids Linn Iowa Raymond Gerald Beranek Ethan Paul Davidson Signed
133 2020-11-15 19:57 Anonymous (not verified) 75.162.166.182 A Metro Snow Removal and lawn care llc 6436 Washington Ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-15 Jeff Lamp Jeff.lamp79@gmail.com Windsor hieghts IA United States Jill Fresh Rick Brown Signed (1) The corporation rejects the employers’ liability coverage. A Metro Snow Removal and lawn Care llc Jeff.lamp79@gmail.com Owner Windsor hieghts IA United States jill Fresh Rick Brown Signed
134 2020-11-16 16:36 Anonymous (not verified) 192.33.191.131 Nekola Outdoors Services, Inc 722 Penrose St, Grinnell IA 50112 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. 2020-11-16 Matthew Lee Nekola NEKOLAOUTDOORSERVICES@GMAIL.COM Grinnell Poweshiek Iowa Josh Lacaeyse Frank Heinen Signed (1) The corporation rejects the employers’ liability coverage. Matthew Lee Nekola nekolaoutdoorservices@gmail.com President Grinnell Poweshiek Iowa Josh Lacaeyse Frank Heinen Signed
137 2020-11-23 10:11 Anonymous (not verified) 207.32.14.70 Community Ambulance Service, Inc. 15 N 1st St., Estherville, IA 51334 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. 2020-11-18 Christopher Fuhrman christopher.furhrman@edwardjones.com Spirit Lake Dickinson Iowa Sara M Fisher Abbie J Fuhrman Signed (1) The corporation rejects the employers’ liability coverage. Christopher Fuhrman christopher.fuhrman@edwardjones.com President Spirit Lake Dickinson Iowa Sara M Fisher Abbie J Fuhrman Signed
135 2020-11-20 11:05 Anonymous (not verified) 208.95.1.97 Burds Communities Inc. 606 S 3rd Street, Bellevue, IA 52031 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-20 Todd Burds burdshousing@yahoo.com Peosta Dubuque IA Paula Fitzgerald Jena Wilwert Signed (1) The corporation rejects the employers’ liability coverage. Todd Burds burdshousing@yahoo.com President Peosta Dubuque IA Paula Fitzgerald Jena Wilwert Signed
136 2020-11-20 11:06 Anonymous (not verified) 208.95.1.97 Burds Communities Inc. 606 S 3rd Street, Bellevue, IA 52031 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-20 Tim Burds burdshousing@yahoo.com Peosta Dubuque IA Paula Fitzgerald Jena Wilwert Signed (1) The corporation rejects the employers’ liability coverage. Tim Burds burdshousing@yahoo.com Vice President Peosta Dubuque IA Paula Fitzgerald Jena Wilwert Signed
355 2021-11-05 15:04 Anonymous (not verified) 209.252.172.87 S&S Window Treatments Inc. 2555 Hwy 1 SW, 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. 2020-11-20 Joshua Yoder installation@bachmeiercarpetone.com Iowa City Johnson Iowa Heather Howell Sarah Coberley Signed (1) The corporation rejects the employers’ liability coverage. Joshua Yoder installation@bachmeiercarpetone.com Owner Iowa City Johnson Iowa Sarah Coberley Heather Howell Signed
138 2020-11-24 14:11 Anonymous (not verified) 173.215.17.41 Dohrmann Enterprises, Inc 2478 260th Ave. DeWitt, Iowa 52742 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. 2020-11-24 Joel Dohrmann dohrmannpnh@gmail.com DE WITT Clinton IA Susanne Owen Daron Oberbroecking Signed (1) The corporation rejects the employers’ liability coverage. Susanne Owen sowen@ohnward.com none Camanche Clinton Iowa Joel Dohrmann Daron Oberbroecking Signed
152 2021-01-04 12:08 Anonymous (not verified) 104.129.206.120 Schleswig Transfer Inc 216 Valley View Dr, Schleswig, IA 51461 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. 2020-11-30 Wade Miller t.uhl3@joemorten.com Schleswig Crawford Iowa Tamara Uhl Amy Meseck Signed (1) The corporation rejects the employers’ liability coverage. Wade Miller t.uhl3@joemorten.com President Schleswig Crawford IA Tamara Uhl Amy Meseck Signed
141 2020-12-02 09:34 Anonymous (not verified) 208.90.15.53 Humboldt Community Daycare, Inc. DBA Kiddie Cats Childcare and Learning Center P.O. Box 93 Dakota City, Ia 50529 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. 2020-12-02 Travis Goedken travisg@cityofhumboldt.org Humboldt Humboldt Iowa Ross Sleiter Lance Dewinter Signed (1) The corporation rejects the employers’ liability coverage. Travis Goedken travisg@cityofhumboldt.org President Humboldt Humboldt Iowa Ross Sleiter Lance Dewinter Signed
142 2020-12-02 09:39 Anonymous (not verified) 208.90.15.53 Humboldt Community Daycare, Inc. DBA Kiddie Cats Childcare and Learning Center P.O. Box 93 Dakota City, Ia 50529 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. 2020-12-02 Angelique Berry dcity@goldfieldaccess.net Algona Kossuth Iowa Ross Sleiter Scott Curran Signed (1) The corporation rejects the employers’ liability coverage. Angelique Berry dcity@goldfieldaccess.net Secretary/Treasurer Algona Kossuth Iowa Ross Sleiter Scott Curran Signed
143 2020-12-02 09:43 Anonymous (not verified) 208.90.15.53 Humboldt Community Daycare, Inc. DBA Kiddie Cats Childcare and Learning Center P.O. Box 93 Dakota City, Ia 50529 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. 2020-12-02 Rob Dickey robd@fsbwc.com Gilmore City Humboldt Iowa Ross Sleiter Scott Curran Signed (1) The corporation rejects the employers’ liability coverage. Rob Dickey robd@fwbwc.com Vice President Gilmore City Humboldt Iowa Ross Sleiter Scott Curran Signed
144 2020-12-04 12:02 Anonymous (not verified) 184.80.177.137 Arlen, LLC 322 6th St SE - Dyersville, Iowa 52040 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. 2020-12-04 Dan Arlen jheims@english-insurance.com Dyersville IA IA Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Joyce Heims joyce.heims1@gmail.com agent Dyersville IA IA Derrick Parsons Joyce Heims Signed
169 2021-01-26 12:20 Anonymous (not verified) 74.84.91.178 Sunset Ridge Winery LLC 12615 Highway 52 North, Dubuque, IA 52002 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. 2020-12-07 John Bonnette jbonnette@yahoo.com Dubuque Dubuque Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. John Bonnette jbonnette@yahoo.com Officer Dubuque Dubuque Iowa Derrick Parsons Brenda Lewis Signed
170 2021-01-26 12:23 Anonymous (not verified) 74.84.91.178 Sunset Ridge Winery LLC 12615 Highway 52 North, Dubuque, IA 52002 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. 2020-12-07 Ann Bonnette jbonnette@yahoo.com Dubuque Dubuque Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Ann Bonnette jbonnette@yahoo.com Officer Dubuque Dubuque Iowa Derrick Parsons Brenda Lewis Signed
168 2021-01-26 12:06 Anonymous (not verified) 74.84.91.178 RAM Services 13276 Harvest Mood Ridge, Sherrill, IA 52073 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-11 Dusty Herbst dustyherbst@hotmail.com Sherrill Dubuque Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Dusty Herbst dustyherbst@hotmail.com President Sherrill Dubuque Iowa Derrick Parsons Brenda Lewis Signed
205 2021-03-10 09:55 Anonymous (not verified) 173.27.221.9 Tri State Archery, Inc 2100 White St, Dubuque IA 52001 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-14 Denise Udelhofen office@tristateoutdoors.net Dubuque Dubuque Iowa Phillip J Meyer Debbie Meyer Signed (2) The corporation declines to reject the employers’ liability coverage. Jeff Udelhofen office@tristateoutdoors.net President Dubuque Dubuque IA Phillip Meyer Debbie Meyer Signed
167 2021-01-26 11:56 Anonymous (not verified) 74.84.91.178 Shea Real Estate LLC 135 Devon Drive, Dubuque, IA 52001 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-17 Lucas Kahl shearealestatellc@gmail.com Dubuque Dubuque Iowa Gabe Drewelow Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Lucas Kahl shearealestatellc@gmail.com President Dubuque Dubuque Iowa Gabe Drewelow Brenda Lewis Signed
145 2020-12-18 07:54 Anonymous (not verified) 173.215.16.15 Dohrmann Enterprises Inc 2652 350th Ave DeWitt, IA 52742 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. 2020-12-18 Tom Dohrmann dohrmannpnh@gmail.com DeWitt Clinton Iowa Susanne Owen Daron Oberbroeckling Signed (1) The corporation rejects the employers’ liability coverage. Tom Dohrmann dohrmannpnh@gmail.com Owner DeWitt Clinton Iowa Susanne Owen Daron Oberbroeckling Signed
149 2020-12-31 14:59 Anonymous (not verified) 216.81.153.249 S&A Holdings LLC 115 N 2nd Street, Fort Dodge, IA 50501 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. 2020-12-21 Surinder Kumar NONE@GMAIL.COM Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Surinder Kumar NONE@GMAIL.COM Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
150 2020-12-31 15:00 Anonymous (not verified) 216.81.153.249 S&A Holdings LLC 115 N 2nd Street, Fort Dodge, IA 50501 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. 2020-12-21 Amritpal Singh amritaust1@gmail.com Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Amritpal Singh amritaust1@gmail.com Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
146 2020-12-22 08:48 Anonymous (not verified) 207.155.115.120 Kafer Lawn Care 206 frentress dr Farley, IA 52046 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. 2020-12-22 Benjamin Terry Hayes benhayes1800@gmail.com Epworth Dubuque IA Adam Kafer Jeffery Sisler Signed (1) The corporation rejects the employers’ liability coverage. Benjamin Terry Hayes benhayes1800@gmail.com Owner Epworth Dubuque IA Adam Kafer Jeffery Sisler Signed
175 2021-02-01 11:20 Anonymous (not verified) 216.51.132.207 VONDERHAAR CONSTRUCTION 33181 OSTERDOCK RD GUTTENBERG IA 52052 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. 2020-12-28 ROBIE VONDERHAAR nicole@cioia.com GUTTENBERG CLAYTON IA JERRY J ROCHFORD NICOLE L PARKER Signed (1) The corporation rejects the employers’ liability coverage. ROBIE VONDERHAAR NICOLE@CIOIA.COM OWNER Guttenberg CLAYTON IA JERRY J ROCHFORD NICOLE L PARKER Signed
147 2020-12-29 13:57 Anonymous (not verified) 208.38.231.99 CJ Construction 2129N Zenith Ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-29 Christine Ekin John Ekin chrohn2009@yahoo.com Davenport Iowa United States Christine Ekin John J Ekin Signed (1) The corporation rejects the employers’ liability coverage. CJ Construction chrohn2009@yahoo.com Co Owner Davenport Iowa United States Christine Ekin John J Ekin Signed
155 2021-01-06 15:50 Anonymous (not verified) 216.81.153.249 Al's Inc DWB CW&T 1509 Richland Drive, Storm Lake, IA 5058 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. 2020-12-29 Robert Bauer NONE@GMAIL.COM Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Robert Bauer NONE@GMAIL.COM Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
156 2021-01-06 15:52 Anonymous (not verified) 216.81.153.249 Al's Inc DWB CW&T 1509 Richland Drive, Storm Lake, IA 5058 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. 2020-12-29 Jon Bauer NONE@GMAIL.COM Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Jon Bauer None@gmail.com Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
157 2021-01-06 15:53 Anonymous (not verified) 216.81.153.249 Al's Inc DWB CW&T 1509 Richland Drive, Storm Lake, IA 5058 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. 2020-12-29 April Coleman NONE@GMAIL.COM Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. April Coleman None@gmail.com Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed