300 |
2021-08-03 12:43 |
Anonymous (not verified) |
97.125.35.240 |
Every Solutions Drywall INC |
713 SE 7th St Des Moines, Iowa 50309 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-03 |
Luis Hernandez |
everysolutiondrywainc@yahoo.com |
Des Moines |
Polk |
Iowa |
Kelly Denger |
Debra Stratton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Luis Hernandez |
everysoloutiondrywainc@yahoo.com |
Owner |
Des Moines |
Polk |
Ia |
Kelly Denger |
Debra Stratton |
Signed |
303 |
2021-08-06 10:12 |
Anonymous (not verified) |
173.28.219.60 |
Travis Systems, Inc. |
2060 Lynncrest Dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-06 |
Travis Remmert |
travis@travissystems.com |
Coralville |
IA |
United States |
Michelle Remmert |
Christine Douglas |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis Remmert |
travis@travissystems.com |
President & CEO |
Coralville |
IA |
United States |
Michelle Remmert |
Christine Douglas |
Signed |
304 |
2021-08-07 03:43 |
Anonymous (not verified) |
50.81.215.27 |
VALLE SERVICES LLC |
6520 N DIVISION ST |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-07 |
LAURA VALLE |
iavalleservicesllc@gmail.com |
DAVENPORT |
IA |
United States |
bryon hakes |
celia valle |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LAURA VALLE |
iavalleservicesllc@gmail.com |
owner |
DAVENPORT |
IA |
United States |
bryon hakes |
celia valle |
Signed |
305 |
2021-08-08 17:02 |
Anonymous (not verified) |
24.119.190.239 |
Shawn Smalls Painting Inc |
2736 South Cedar Street, Sioux City, IA 51106 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-08 |
David Shawn Small |
smallspaintingsc@gmail.com |
Sioux City |
Woodbury |
Iowa |
Douglas Wiliam Ball |
Ruth Elaine Ball |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Shawn Small |
smallspaintingsc@gmail.com |
Owner |
SIoux City |
Woodbury |
Iowa |
Douglas William Ball |
Ruth Elaine Ball |
Signed |
307 |
2021-08-13 15:21 |
Anonymous (not verified) |
65.154.100.34 |
World of Reptiles Inc dba Snakes Alive |
3901 NW Seasons Ct Ankeny, IA 50023 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-09 |
Ron Goodman |
ron_goo@msn.com |
Ankeny |
Polk |
IA |
Megan Matlock |
Tom Weidner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ron Goodman |
ron_goo@msn.com |
Owner |
Ankeny |
Polk |
IA |
Megan Matlock |
Tom Weidner |
Signed |
308 |
2021-08-13 15:23 |
Anonymous (not verified) |
65.154.100.34 |
World of Reptiles Inc dba Snakes Alive |
3901 NW Seasons Ct Ankeny, IA 50023 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-09 |
Tom Weidner |
mmatlock@thedanaco.com |
Des Moines |
Polk |
IA |
Megan Matlock |
Ron Goodman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tom Weidner |
mmatlock@thedanaco.com |
Owner |
Des Moines |
Polk |
IA |
Megan Matlock |
Ron Goodman |
Signed |
311 |
2021-08-16 12:25 |
Anonymous (not verified) |
65.154.100.34 |
World of Reptiles Inc dba Snakes Alive |
3901 NW Seasons Ct Ankeny, IA 50023 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-09 |
Ron Goodman |
mmatlock@thedanaco.com |
Ankeny |
Polk |
IA |
Megan Matlock |
Tom Weidner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ron Goodman |
mmatlock@thedanaco.com |
Owner |
Ankeny |
Polk |
IA |
Megan Matlock |
Tom Weidner |
Signed |
306 |
2021-08-11 17:03 |
Anonymous (not verified) |
208.73.53.194 |
Dave Sturges Trucking Inc |
16244 170th St. Rockwell, IA 50469 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-11 |
Joseph d sturges |
sturgtrucking@gmail.com |
Rockwell, IA |
Cerro Gordo |
IA |
Connie Downing |
Darc Schropshire |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brian Sturges |
briansturges@netins.net |
President |
Rockwell, Ia |
Cerro Gordo |
IA |
Connie Downing |
Darc Schropshire |
Signed |
325 |
2021-09-03 12:50 |
Anonymous (not verified) |
173.19.58.159 |
Oskaloosa Entertainment Inc. |
507 High Ave W Oskaloosa, IA 52577 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-11 |
Minesh Patel |
djraj007@gmail.com |
Oskaloosa |
Mahaska |
Iowa |
Joe Mauro |
Randy Mauro |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Joe Mauro |
joe@mauroinsurance.net |
insurance agent |
DES MOINES |
Polk |
Iowa |
Joe Mauro |
Randy Mauro |
Signed |
326 |
2021-09-03 12:56 |
Anonymous (not verified) |
173.19.58.159 |
Oskaloosa Entertainment Inc. |
507 High Ave W Oskaloosa, IA 52577 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-11 |
Rajan Devan |
djraj007@gmail.com |
West Des Moines |
Polk |
Iowa |
Joe Mauro |
Randy Mauro |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Joe Mauro |
joe@mauroinsurance.net |
insurance agent |
DES MOINES |
Polk |
United States |
Joe Mauro |
Randy Mauro |
Signed |
323 |
2021-08-30 12:22 |
Anonymous (not verified) |
173.19.179.111 |
OKOBOJI TREE SPECIALISTS II iNC |
PO BOX 515 MILFORD, IA 51351 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-13 |
THOMAS WRIGHT |
joel@walkerinsuranceia.com |
MILFORD |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
THOMAS WRIGHT |
joel@walkerinsuranceia.com |
ADMIN |
ST PAUL |
MN |
55106 |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
309 |
2021-08-16 10:36 |
Anonymous (not verified) |
71.86.215.206 |
st ansgar historic school project, inc |
po box 52 st ansgar IA 50472 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-16 |
tammi kofoot |
tammykofoot@gmail.com |
st ansgar |
mitchell |
ia |
julie thome |
dale blakestad |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
tyler mckinley |
tbmckinley@gmail.com |
treasurer |
rochester |
mn |
olmsted |
julie thome |
dale blakestad |
Signed |
310 |
2021-08-16 10:37 |
Anonymous (not verified) |
71.86.215.206 |
st ansgar historic school project, inc |
po box 52 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-16 |
dana wold |
dawold@woldinc.com |
st ansgar |
mitchell |
ia |
julie thome |
dale blakestad |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
tyler mckinley |
tbmckinley@gmail.com |
treasurer |
rochester |
olmsted |
mn |
julie thome |
dale blakestad |
Signed |
312 |
2021-08-18 22:29 |
Anonymous (not verified) |
166.181.81.19 |
Basset Express Inc. |
1572 Underwood Ave. |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-18 |
Jay R Chelf |
bassetexpress@yahoo.com |
Muscatine |
Muscatine |
IA |
Bill Petersen |
Jody L Young |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Patricia Ann Chelf |
bassetexpress@gmail.com |
President |
Muscatine |
Muscatine |
Iowa |
Bill Petersen |
Jody L Young |
Signed |
313 |
2021-08-19 10:28 |
Anonymous (not verified) |
216.81.153.249 |
Bailey01 LLC |
3020 S Cypress, Sioux City, IA 51106 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-19 |
Gordon Hagen |
gordonhagen1@outlook.com |
Sioux City |
Woodbury |
Iowa |
Jared Brashears |
Mary Jo Olthoff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gordon Hagen |
gordonhagen1@outlook.com |
Owner |
Sioux City |
Woodbury |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
314 |
2021-08-19 12:58 |
Anonymous (not verified) |
173.26.33.84 |
CLINK FM, INC. |
110 N. Maryville Street, Calmar, IA 52132 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-19 |
Jesse Y Goplen |
jessegoplen@gmail.com |
Oelwein |
Fayette |
IA |
Della Nehring |
Tim Nehring |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kyana Taillon |
kyana@clink.fm |
Co-Founder/Vice-President |
Oelwein |
Fayette |
IA |
Della Nehring |
Tim Nehring |
Signed |
315 |
2021-08-19 13:08 |
Anonymous (not verified) |
173.26.33.84 |
CLINK FM, Inc. |
110 N. Maryville Street |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-19 |
Kyana B Taillon |
kyanalily@gmail.com |
Oelwein |
Fayette |
IA |
Della Nehring |
Tim Nehring |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jesse Y Goplen |
jesse@clink.fm |
Co-Founder/President |
Oelwein |
Fayette |
IA |
Della Nehring |
Tim Nehring |
Signed |
319 |
2021-08-24 10:19 |
Anonymous (not verified) |
174.243.114.142 |
Sabbatical Services LLC |
20732 Johnson St., Milo, IA 50166 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-24 |
Bryce Gilbert |
bryce.ssllc@outlook.com |
Milo |
Warren |
Iowa |
Kathryn Gilbert |
Kolton Gilbert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bryce Gilbert |
bryce.ssllc@outlook.com |
President |
Milo |
Warren |
Iowa |
Kathryn Gilbert |
Kolton Gilbert |
Signed |
335 |
2021-09-16 17:22 |
Anonymous (not verified) |
64.142.5.50 |
Electrious Inc DBA Clean Tech |
1110 Alhambra Ave Martinez CA 94533. |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-26 |
Robert Lemos |
robbie.lemos@clean.tech |
San Ramon |
Contra Costa County |
CA |
Teresa Leibnitz |
Greg Vermeulen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robbie Lemos |
robbie.lemos@clean.tech |
CEO |
San Ramon |
Contra Costa County |
CA |
Teresa Leibnitz |
Greg Vermeulen |
Signed |
336 |
2021-09-16 18:53 |
Anonymous (not verified) |
64.142.5.50 |
Electrious Inc DBA Clean Tech |
1110 Alhambra Ave Martinez CA 94533. |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-26 |
Petr Brazdil |
petr.brazdil@clean.tech |
Trida Spojencu |
Brno |
Czechia in Europe |
Robbie Lemos |
Teresa Leibnitz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robbie Lemos |
robbie.lemos@clean.tech |
CEO |
SAN RAMON |
Contra Costa County |
CA |
Robbie Lemos |
Teresa Leibnitz |
Signed |
324 |
2021-08-31 09:19 |
Anonymous (not verified) |
76.84.58.43 |
Dave's Lawn Care |
716 4th Ave Nebraska City NE68410 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-01 |
David Wilberger |
daveslawncare00@gmail.com |
NEBRASKA CITY |
NE |
United States |
Linda Bowers |
Thomas Hume |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Wilberger |
daveslawncare00@gmail.com |
owner |
Nebraska City |
Otoe |
NE |
Linda Bowers |
Thomas Hume |
Signed |
530 |
2022-09-02 13:17 |
Anonymous (not verified) |
173.20.146.6 |
Nicci Keck LLC |
1107 Pheasant Valley St, Iowa City, IA 52246 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-02 |
Nicole Keck |
niccikeckllc@gmail.com |
Iowa City |
Johnson |
Iowa |
Evangeline Kadera |
Denise Kandel |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nicole Keck |
niccikeckllc@gmail.com |
Managing Member/Owner/President |
Iowa City |
Johnson |
Iowa |
Evangeline Kadera |
Denise Kandel |
Signed |
531 |
2022-09-02 13:19 |
Anonymous (not verified) |
173.20.146.6 |
Nicci Keck LLC |
1107 Pheasant Valley St, Iowa City, IA 52246 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-02 |
Benjamin Darbro |
darbrob@gmail.com |
Iowa City |
Johnson |
Iowa |
Evangeline Kadera |
Denise Kandel |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nicole Keck |
niccikeckllc@gmail.com |
Managing Member/Owner/President |
Iowa City |
Johnson |
Iowa |
Evangeline Kadera |
Denise Kandel |
Signed |
349 |
2021-10-22 11:08 |
Anonymous (not verified) |
63.152.48.235 |
Strong Rock and Gravel LLC |
721 S Front St, Lansing, IA 52151 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-04 |
Ronald Strong |
stronggravel@gmail.com |
Llansing |
Allamakee |
Iowa |
James H Bieber |
Jane Tepesch |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James H Bieber |
biebinre@qwestoffice.net |
Insurance Agent |
WAUKON |
Allamakee |
Iowa |
James H Bieber |
Jane Tepesch |
Signed |
327 |
2021-09-07 08:58 |
Anonymous (not verified) |
173.28.32.129 |
Sas Entertainment, Inc. |
PO Box 47 LeClaire, IA 52753 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-07 |
Randy Saskowski |
sales@sasdjs.com |
Geneseo |
henry |
illinois |
Dan Terry |
Joe Roberts |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
randy Saskowski |
sales@sasdjs.com |
President |
Geneseo |
henry |
illinois |
Dan Terry |
Joe Roberts |
Signed |
328 |
2021-09-08 08:31 |
Anonymous (not verified) |
97.125.157.23 |
Dan Petersen Construction |
1725 S 14th St, Polk City, IA 50026 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-08 |
Daniel Petersen |
danpetersenconstruction@gmail.com |
Polk City |
Polk County |
Iowa |
Jim McMurray |
Erik Gramenz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Petersen |
danpetersenconstruction@gmail.com |
Owner |
Polk City |
Polk |
Iowa |
Jim McMurray |
Erik Gramenz |
Signed |
329 |
2021-09-08 10:18 |
Anonymous (not verified) |
206.80.128.71 |
H F Corporation |
105 E Oskaloosa Pella, IA 50219 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-08 |
Bharat Patel |
super8pella@gmail.com |
Pella |
Marion |
Iowa |
Mark Chambers |
Jim Wessels |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeremy Rogstad |
jeremy@jeremyrogstad.com |
State Farm Agent |
Iowa |
Floyd |
Iowa |
Mark Chambers |
Jim Wessels |
Signed |
330 |
2021-09-08 10:20 |
Anonymous (not verified) |
206.80.128.71 |
H F Corporation |
105 Oskaloosa St Pella, IA 50219 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-08 |
Nayan Patel |
super8pella@gmail.com |
Pella |
Marion |
Iowa |
Mark Chambers |
Jim Wessels |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeremy Rogstad |
jeremy@jeremyrogstad.com |
State Farm Agent |
Charles City |
Floyd |
Iowa |
Mark Chambers |
Jim Wessels |
Signed |
331 |
2021-09-08 10:21 |
Anonymous (not verified) |
206.80.128.71 |
H F Corporation |
105 Oskaloosa St Pella, IA 50219 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-08 |
Dinesh Patel |
super8pella@gmail.com |
Pella |
Marion |
Iowa |
Mark Chambers |
Jim Wessels |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeremy Rogstad |
jeremy@jeremyrogstad.com |
State Farm Agent |
Charles City |
Floyd |
Iowa |
Mark Chambers |
Jim Wessels |
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 |
333 |
2021-09-14 14:53 |
Anonymous (not verified) |
147.0.156.50 |
O'Danny Boy Builders, Inc. |
7512 S. County Line Rd., Suite #4, Burr Ridge, IL 60527 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-14 |
Daniel Flanagan |
jflanagan@odannyboybuilders.com |
LaGrange |
Cook |
Illinois |
John Flanagan |
Mark Hayes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Flanagan |
Jflanagan@odannyboybuilders.com |
Executive |
Western Springs |
Cook |
IL |
Ben Weed |
Mark Hayes |
Signed |
334 |
2021-09-14 16:24 |
Anonymous (not verified) |
67.129.252.2 |
Nextec |
4050 Westmark Drive, Dubuque, Iowa 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. |
2021-09-14 |
Susan Kern |
skern@kendallhunt.com |
Dubuque |
Dubuque |
Iowa |
Paul Kern |
Matthew Johnston |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Greg Feltes |
gfeltes@westmarkdevelopment.com |
Officer |
Dubuque |
Dubuque |
Iowa |
Dana Feltes |
Cole Feltes |
Signed |
337 |
2021-09-16 21:28 |
Anonymous (not verified) |
173.17.8.56 |
Hutch's Parking Lot Sweeping Inc. |
5235 Jennifer Dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-16 |
Bill E Hutchinson |
btnwhutch@aol.com |
Pleasant Hill |
Iowa |
Iowa |
Tracy Hutchinson |
Nic Hutchinson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill E Hutchinson |
btnwhutch@aol.com |
Same |
Pleasant Hill |
Iowa |
Iowa |
Tracy Hutchinson |
Nic Hutchinson |
Signed |
338 |
2021-09-22 10:34 |
Anonymous (not verified) |
216.81.153.249 |
APS LLC |
904 Lake Avenue |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-22 |
Amrit Singh |
amritaust1@gmail.com |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Amrit Singh |
amritaust1@gmail.com |
Owner |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
350 |
2021-10-25 08:22 |
Anonymous (not verified) |
208.95.64.3 |
Ron Sexton Construction Inc, |
1184 Vine Ave, Riverside IA 52327 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-27 |
Ronald R Sexton |
ashmac@iowatelecom.net |
Riverside |
Washington |
IA |
Greg Martin |
Michele McMichael |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ronald R Sexton |
ashmac@iowatelecom.net |
President |
Riverside |
Washington |
IA |
Greg Martin |
Michele McMichael |
Signed |
351 |
2021-10-25 08:24 |
Anonymous (not verified) |
208.95.64.3 |
Ron Sexton Construction Inc, |
1184 Vine Ave, Riverside IA 52327 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-27 |
Theresa A Sexton |
ashmac@iowatelecom.net |
Riverside |
Washington |
IA |
Greg Martin |
Michele McMichael |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Theresa A Sexton |
ashmac@iowatelecom.net |
VP, Secretary, Treasurer |
Riverside |
Washington |
IA |
Greg Martin |
Michele McMichael |
Signed |
340 |
2021-10-01 15:44 |
Anonymous (not verified) |
3.217.29.203 |
Tracy Countryman |
745 Robert Drive Moville, IA 51039 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-30 |
Tracy Countryman |
Tracycountryman@ymail.com |
Moville |
Woodbury |
Iowa |
Deborah Clark |
Jane Ashley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tracy Countryman |
Tracycountryman@ymail.com |
President |
Moville |
Woodbury |
Iowa |
Deborah Clark |
Jane Ashley |
Signed |
342 |
2021-10-06 11:02 |
Anonymous (not verified) |
192.95.124.125 |
Jeffrey Wilharm MDPC |
9100 C St., Cedar Rapids, IA 52404-9160 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-06 |
Jeffrey Wilharm |
wilharmjeffrey@gmail.com |
Cedar Rapids |
Linn |
IA |
John Yundt |
Lori Smith |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey Wilharm |
wilharmjeffrey@gmail.com |
President |
Cedar Rapids |
Linn |
IA |
John Yundt |
Lori Smith |
Signed |
343 |
2021-10-07 15:12 |
Anonymous (not verified) |
73.191.238.89 |
Kleaveland Brothers, Inc. |
c/o 5724 36th Avenue NE, Seattle, WA 98105 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-07 |
Michael I. Kleaveland |
kleaveland@comcast.net |
Muskegon |
Muskegon |
MI |
Amanda A. Finch |
Enrika L.F. McGahan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael I. Kleaveland |
kleaveland@comcast.net |
Secretary/Treasurer |
Muskegon |
Muskegon |
MI |
Amanda A. Finch |
Enrika L.F. McGahan |
Signed |
344 |
2021-10-07 15:22 |
Anonymous (not verified) |
73.191.238.89 |
Kleaveland Brothers, Inc |
c/o 5724 36th Avenue, Ne. Seattle, WA 98105 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-07 |
I. Justin Kleaveland |
justinqt@comcast.net |
North Muskegon |
Muskegon |
MI |
Amanda A. Finch |
Enrika L.F. McGahan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
I. Justin Kleaveland |
justinqt@comcast.net |
Vice President |
North Muskegon |
Muskegon |
MI |
Amanda A. Finch |
Enrika L.F. McGahan |
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 |
345 |
2021-10-11 15:36 |
Anonymous (not verified) |
173.188.10.36 |
Outdoor Pros LLC |
4525 HWY 22 SE |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-11 |
Erik Scott Alberhasky |
erikalberhas@gmail.com |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik Scott Alberhasky |
erikalberhas@gmail.com |
Owner |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
346 |
2021-10-14 13:54 |
Anonymous (not verified) |
75.162.50.106 |
Dawn's Daycare & Educational Program |
360 NW Walnut Ave, Earlham, Iowa 50072 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-14 |
Dawn Lynnete Stonehocker |
daycare.dawn@gmail.com |
Earlham |
Madison |
Iowa |
Anne Marie Larson |
Alison Renae Werts |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dawn Lynnette Stonehocker |
daycare.dawn@gmail.com |
Self |
Earlham |
Madison |
Iowa |
Anne Marie Larson |
Alison Renae Werts |
Signed |
347 |
2021-10-14 19:28 |
Anonymous (not verified) |
75.162.50.106 |
Dawn's Daycare |
360 NW Walnut Ave Earlham,Iowa 50072 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-14 |
James J Stonehocker |
j_stonehocker@hotmail.com |
Earlham |
Madison |
iowa |
Anne Larson |
Alison Werts |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James J Stonehocker |
j_stonehocker@hotmail.com |
Owner |
Earlham |
Madison |
Iowa |
Anne Larson |
Alison Werts |
Signed |
348 |
2021-10-20 11:06 |
Anonymous (not verified) |
97.116.100.220 |
Gonzalo construction LLC |
5517 Brookdale Dr n apt 105 Brooklyn Park, mn 55443 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-20 |
Gonzalo Roman robles |
gonzaloconstructionmn@gmail.com |
Brooklyn park |
Hennepin |
Minnesora |
Gonzalo Roman robles |
Ashley Kraft |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gonzalo Roman robles |
gonzaloconstruction@gmail.com |
Owner |
Brooklyn park |
Hennepin |
Minnesota |
Gonzalo Roman robles |
Ashley Kraft |
Signed |
358 |
2021-11-15 09:39 |
Anonymous (not verified) |
165.225.57.41 |
Jerry Steward Trucking Inc. |
319 W. 7th Street, Janesville, IA 50647 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-22 |
Jerry Steward Sr. |
cedarfalls.oil@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jerry Steward Jr. |
cedarfalls.oil@gmail.com |
Vice-President |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
359 |
2021-11-15 09:43 |
Anonymous (not verified) |
165.225.57.41 |
Jerry Steward Trucking Inc |
319 W. 7th Street, Janesville, IA 50647 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-22 |
Jerry Steward Jr. |
cedarfalls.oil@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jerry Steward Sr. |
cedarfalls.oil@gmail.com |
President |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
360 |
2021-11-15 09:47 |
Anonymous (not verified) |
165.225.57.41 |
Jerry Steward Trucking Inc |
319 W. 7th Street, Janesville, IA 50647 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-22 |
Ruth Steward |
cedarfalls.oil@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jerry Steward Sr. |
cedarfalls.oil@gmail.com |
President |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
363 |
2021-11-17 09:33 |
Anonymous (not verified) |
64.5.67.201 |
OC Deliver Inc |
207 Central Avenue NE, Orange City, IA 51041 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-25 |
Joe Clarey |
ciui@orangecitycomm.net |
LeMars |
Plymouth |
Iowa |
Daryl Beltman |
Lori Mars |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joe Clarey |
ciui@orangecitycomm.net |
President |
LeMars |
Plymouth |
Iowa |
Daryl Beltman |
Lori Mars |
Signed |
364 |
2021-11-17 09:36 |
Anonymous (not verified) |
64.5.67.201 |
OC Deliver Inc |
207 Central Avenue NE, Orange City, IA 51041 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-25 |
Josh Van Es |
ciui@orangecitycomm.net |
Orange City |
Sioux |
Iowa |
Daryl Beltman |
Lori Mars |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Josh Van Es |
ciui@orangecitycomm.net |
Secretary/Treasurer |
Orange City |
Sioux |
Iowa |
Daryl Beltman |
Lori Mars |
Signed |