401 |
2022-02-08 11:16 |
Anonymous (not verified) |
173.29.121.248 |
NW Bender LLC DBA Agent Clean |
3229 E Ovid 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. |
2022-02-07 |
Nikolas W Bender |
Nikolas@agentclean.com |
Des Moines |
Polk |
Iowa |
Stan Mohr |
Victor Flores |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nikolas W Bender |
Nikolas@agentclean.com |
Self |
Des Moines |
Polk |
Iowa |
Stan Mohr |
Victor Flores |
Signed |
402 |
2022-02-09 09:46 |
Anonymous (not verified) |
69.57.33.202 |
Toby K's Hideaway Inc. dba Toby K's Hideaway |
1723 Mamie Eisenhower Ave, Boone IA 50036 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-02-09 |
Toby Kruse |
samanthapeck@boehmins.com |
Boone |
Boone |
Iowa |
Samantha Peck |
Hans Boehm |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Toby Kruse |
samanthapeck@boehmins.com |
Owner |
Boone |
Boone |
Iowa |
Samantha Peck |
Hans Boehm |
Signed |
408 |
2022-02-18 11:30 |
Anonymous (not verified) |
173.31.148.43 |
PACKEBUSH SPRINKLER SERVICE INC |
1960 170TH AVE MILFORD, IA 51351 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-02-09 |
ROSS PACKEBUSH |
RKPACKEBUSH@GMAIL.COM |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ROSS PACKEBUSH |
joel@walkerinsuranceia.com |
PRESIDENT |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
409 |
2022-02-18 11:32 |
Anonymous (not verified) |
173.31.148.43 |
PACKEBUSH SPRINKLER SERVICE INC |
1960 170TH AVE MILFORD, IA 51351 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-02-09 |
KARA PACKEBUSH |
RKPACKEBUSH@GMAIL.COM |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
KARA PACKEBUSH |
JOEL@WALKERINSURANCEIA.COM |
VICE PRESIDENT |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
404 |
2022-02-13 12:50 |
Anonymous (not verified) |
217.180.228.177 |
Premier Property Group LLC |
8805 Chambery Blvd Ste 300 #217 Johnston, IA 50131 |
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. |
2022-02-13 |
Cade Montgomery |
ppgiowallc@gmail.com |
Johnston |
Polk |
Iowa |
Cailey Montgomery |
Sara Saylor |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cade Montgomery |
ppgiowallc@gmail.com |
Owner |
Johnston |
Polk |
Iowa |
Cailey Montgomery |
Sara Saylor |
Signed |
405 |
2022-02-14 10:36 |
Anonymous (not verified) |
207.199.239.234 |
My Nest Greenhouse |
1134-1600 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. |
2022-02-14 |
Patti Bogler |
mynest@fmctc.com |
Harlan |
Iowa |
Iowa |
Hallie Carroll |
Katrina Shea |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Patti Bogler |
mynest@fmctc.com |
owner |
Harlan |
Iowa |
Iowa |
Hallie Lynn Carroll |
Katrina Mae Shea |
Signed |
406 |
2022-02-15 17:30 |
Anonymous (not verified) |
173.18.126.91 |
Huff Construction |
1309 Business 30 sw Mount Vernon IA |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-02-15 |
Jason Huff |
jason@huff-construction.com |
Mount Vernon |
Linn |
Iowa |
Katie Huff |
Rick Deneve |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jason Huff |
jason@huff-construction.com |
Owner |
Mount Vernon |
Linn |
Iowa |
Katie Huff |
Rick Deneve |
Signed |
459 |
2022-04-29 08:49 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West ave Baxter. IA 50028 |
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. |
2022-02-15 |
David Kirkman |
kirkcola@gmail.com |
Newton |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rick Thatcher |
rickswrecks@gmail.com |
President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
407 |
2022-02-16 15:44 |
Anonymous (not verified) |
173.18.126.91 |
Huff Construction LLC |
1309 Business 30 Sw |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-02-16 |
Jason Huff |
jason@huff-construction.com |
Mount Vernon |
Linn |
Iowa |
Katie Huff |
Rick Deneve |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jason Huff |
jason@huff-construction.com |
Owner |
Mount Vernon |
Linn |
Iowa |
Katie Huff |
Rick Deneve |
Signed |
605 |
2023-02-17 11:29 |
Anonymous (not verified) |
94.188.207.223 |
McDonald Construction |
617 Kingsley Ave, Waterloo Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-02-17 |
Todd Gelner |
toddandabbey@yahoo.com |
Denver |
Bremer |
Iowa |
Abbey Gelner |
Abbey Elizabeth-Anne Gelner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Todd Gelner |
toddandabbey@yahoo.com |
Self |
Denver |
Bremer |
Iowa |
Abbey Gelner |
Karen Henry |
Signed |
410 |
2022-02-20 19:10 |
Anonymous (not verified) |
173.27.233.68 |
A and W marble and tile Inc |
207 Philip St. Des Moines, Iowa 50315 |
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. |
2022-02-20 |
Wayne Yergy |
wyergy@gmail.com |
Des Moines |
Polk |
Iowa |
John Noga |
Angie Carter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Wayne A Yergy |
wyergy@gmail.com |
Vice President |
Des Moines |
IA |
United States |
John Noga |
Angie Carter |
Signed |
411 |
2022-02-23 15:06 |
Anonymous (not verified) |
173.19.163.201 |
DK Pluming and Excavating |
12439 S 60TH AVE W |
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. |
2022-02-23 |
JAMES DONAHOO |
DKPIPELLC@GMAIL.COM |
PRAIRIE CITY |
Jasper |
IA |
David Graber |
Matt Bengston |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Donahoo |
DKPIPELLC@GMAIL.COM |
Owner |
PRAIRIE CITY |
Jasper |
IA |
David Graber |
Matt Bengston |
Signed |
412 |
2022-02-23 15:42 |
Anonymous (not verified) |
208.126.112.220 |
Bergmann Bros. Excavating & Trucking |
PO Box G, Frederika, IA 50631 |
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. |
2022-02-23 |
Kenny A. Bergmann |
kennb@butler-bremer.com |
Frederika |
Bremer |
Iowa |
Ronald A. Bergmann |
Tad M. Chapin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kenny A. Bergmann |
kennb@butler-bremer.com |
self |
Frederika |
Bremer |
Iowa |
Ronald A. bergmann |
Tad M. Chapin |
Signed |
413 |
2022-02-23 16:31 |
Anonymous (not verified) |
184.80.177.137 |
T-Rex Hospitality LLC, DBA FUSE |
120 Twin Steeples Circle, Dyersville Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-02-23 |
Tara Rahe |
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 |
414 |
2022-02-25 08:10 |
Anonymous (not verified) |
70.100.125.106 |
Coachlight Condominium Owners Association |
714 14th Ave N, 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. |
2022-02-25 |
Lowell W Cornwell |
lwcornwell@frontiernet.net |
Fort Dodge |
Webster |
IA |
Randy Ranthum |
Paul Templemeyer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Alan Wooters |
shirise@wtcta.net |
President |
Fort Dodge |
Webster |
IA |
Jackie Jacobs |
Paula Templemeyer |
Signed |
415 |
2022-02-25 08:13 |
Anonymous (not verified) |
70.100.125.106 |
Coachlight Condominium Owners Association |
714 14th Ave N, 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. |
2022-02-25 |
Joyce Hanson |
jmhanson820@outlook.com |
Fort Dodge |
Webster |
IA |
Randy Ranthum |
Jackie Jacobs |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Alan Wooters |
shirise@wtcta.net |
President |
Fort Dodge |
Webster |
IA |
Jackie Jacobs |
Paula Templemeyer |
Signed |
416 |
2022-02-25 08:15 |
Anonymous (not verified) |
70.100.125.106 |
Coachlight Condominium Owners Association |
714 14th Ave N, 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. |
2022-02-25 |
Alan Wooters |
shirise@wtcta.net |
Fort Dodge |
Webster |
IA |
Randy Ranthum |
Paul Templemeyer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Alan Wooters |
shirise@wtcta.net |
President |
Fort Dodge |
Webster |
IA |
Jackie Jacobs |
Paula Templemeyer |
Signed |
417 |
2022-03-03 13:20 |
Anonymous (not verified) |
67.41.107.230 |
Trility Group Holdings, Inc. |
14001 University Ave, Suite 300, Clive, IA 50125 |
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. |
2022-03-03 |
Brenton David Rothchild |
brenton@trility.io |
Indianola |
Warren |
IA |
Devin Boyer |
Kyle Woiwood |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brenton David Rothchild |
brenton@trility.io |
Treasurer |
Indianola |
Warren |
IA |
Devon Boyer |
Kyle Woiwood |
Signed |
418 |
2022-03-03 14:29 |
Anonymous (not verified) |
72.255.79.18 |
Ostafi Communication Inc. |
2121 Swan Dr. Camanche, IA 52730 |
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. |
2022-03-03 |
Eduard Ostafi |
ostaficommunication@gmail.com |
Camanche |
Clinton |
IA |
Stephanie Millage |
Amanda Van Theemsche |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Eduard Ostafi |
ostaficommunication@gmail.com |
President |
Camanche |
Clinton |
IA |
Stephanie Millage |
Amanda Van Theemsche |
Signed |
419 |
2022-03-03 14:37 |
Anonymous (not verified) |
68.13.47.145 |
Trility Group Holdings, Inc |
14001 University Ave, Suite 300 |
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. |
2022-03-03 |
James Brody Deren |
brody@trility.io |
Omaha |
Douglas |
Nebraska |
Devin Boyer |
Kyle Woiwood |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Brody Deren |
brody@trility.io |
Secretary |
Omaha |
Douglas |
Nebraska |
Devin Boyer |
Kyle Woiwood |
Signed |
420 |
2022-03-04 13:58 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise LLC |
101 Ashworth Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-04 |
Mustafa Keserovic |
MustafaKeserovic@gmail.com |
Ankeny |
Pokl |
Iowa |
Sandro Tadic |
Andrew Swanson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandro Tadic |
sanienterprise14@gmail.com |
Owner |
WEST DES MOINES |
Iowa |
United States |
Sandro Tadic |
Andrew swanson |
Signed |
421 |
2022-03-07 17:14 |
Anonymous (not verified) |
174.215.244.140 |
MJ Kunkel Trucking, LLC |
403 N Ash 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. |
2022-03-07 |
Michael John Kunkel |
mjkunkeltrucks@gmail.com |
Marcus |
IA |
United States |
Adam Bartels |
Karlee Ohrt |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael John Kunkel |
mikekunkel0361@gmail.com |
Self |
Marcus |
IA |
United States |
Adam Bartels |
Karlee Ohrt |
Signed |
422 |
2022-03-08 08:56 |
Anonymous (not verified) |
98.16.51.166 |
Trility Group Holdings, Inc. |
14001 University Avenue, Suite 300, Clive IA 50125 |
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. |
2022-03-08 |
Matthew D Edwards |
matthew@trility.io |
New Virginia |
Warren |
Iowa |
Devin Boyer |
Kyle Woiwood |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Matthew D Edwards |
matthew@trility.io |
President |
New Virginia |
Warren |
Iowa |
Devin Boyer |
Kyle Woiwood |
Signed |
424 |
2022-03-11 15:36 |
Anonymous (not verified) |
69.63.16.2 |
BR Flynn Co Inc |
16756 Corey Daniel Ct, 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. |
2022-03-11 |
Bruce R Flynn |
br.flynn4@gmail.com |
Dubuque |
Dubuque |
Iowa |
Rick Meyer |
Dyan Kriener |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bruce R Flynn |
br.flynn4@gmail.com |
President |
Dubuque |
Dubuque |
IA |
Rick Meyer |
Dyan Kriener |
Signed |
425 |
2022-03-16 07:57 |
Anonymous (not verified) |
173.29.149.199 |
Schult Industries Inc |
PO Box 165 Camanche, IA 52730 |
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. |
2022-03-17 |
MIKE SCHULT |
mschult10@gmail.com |
CLINTON |
Clinton |
Iowa |
Rhonda Schult |
Lance VanDeest |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
MIKE SCHULT |
mschult10@gmail.com |
Owner |
CLINTON |
Clinton |
Iowa |
Rhonda Schult |
Lance VanDeest |
Signed |
426 |
2022-03-22 12:06 |
Anonymous (not verified) |
69.54.105.130 |
Downing Development, Ltd. |
13004 NW 44th St Polk City, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-22 |
Carolyn Suzanne Downing |
susiedowningdevelopment@gmail.com |
Polk City |
IA |
United States |
Geneva Aki Ross |
Amy Sue Romero |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carolyn Suzanne Downing |
susiedowningdevelopment@gmail.com |
Secretary |
Polk City |
Polk County |
Iowa |
Geneva Aki Ross |
Amy Sue Romero |
Signed |
427 |
2022-03-22 12:08 |
Anonymous (not verified) |
69.54.105.130 |
Downing Development, Ltd. |
13004 NW 44th St Polk City, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-22 |
Steven Jeffrey Downing |
stevedowningdevelopment@gmail.com |
Polk City |
Polk County |
Iowa |
Geneva Aki Ross |
Amy Sue Romero |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Steven Jeffrey Downing |
stevedowningdevelopment@gmail.com |
President |
Polk City |
Polk County |
Iowa |
Geneva Aki Ross |
Amy Sue Romero |
Signed |
428 |
2022-03-23 12:00 |
Anonymous (not verified) |
76.76.231.229 |
Connelly Sanitation Inc |
108 S. 14th St. Fairfield IA 52556 |
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. |
2022-03-23 |
Richard Raymond Vogt |
connelly.inc@outlook.com |
Fairfield |
Jefferson |
Iowa |
Mindy Lynn Vogt |
Chester James Vogt |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Richard Raymond Vogt |
connelly.inc@outlook.com |
Self |
Fairfield |
Jefferson |
Iowa |
Mindy Lynn Vogt |
Chester James Vogt |
Signed |
429 |
2022-03-24 13:37 |
Anonymous (not verified) |
174.255.1.155 |
Franky's Construction |
1419 Acacia Dr NE, Cedar Rapids, IA 52402 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-24 |
Frank Ackley |
fackley1981@gmail.com |
Cedar Rapids |
Linn |
IA |
Rick Deneve |
Kailee Carstensen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Franky Ackley |
fackley1981@gmail.com |
Owner |
Cesar Rapids |
Linn |
IA |
Rick DeNeve |
Kailee Carstensen |
Signed |
430 |
2022-03-24 14:47 |
Anonymous (not verified) |
173.30.76.116 |
Franky's Construction |
1419 Acacia Dr NE, Cedar Rapids, IA 52402 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-24 |
Franky Ackley |
fackley1981@gmail.com |
Cedar Rapids |
Linn |
IA |
Rick DeNeve |
Kailee Carstensen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Franky Ackley |
fackley1981@gmail.com |
Owner |
Cedar Rapids |
Linn |
IA |
Rick DeNeve |
Kailee Carstensen |
Signed |
436 |
2022-03-29 11:07 |
Anonymous (not verified) |
184.80.177.137 |
Adam Sheppard |
22194 260th St - Delhi, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-24 |
Adam Sheppard |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Sheppard |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
431 |
2022-03-25 15:47 |
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. |
2022-03-25 |
Maria A Ney |
maria@neytrucking.com |
Peosta |
Dubuque |
IA |
Brenda Weatherwax |
Becky Schmelzer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Maria Ney |
maria@neytrucking.com |
President |
Peosta |
Dubuque |
IA |
Brenda Weatherwax |
Becky Schmelzer |
Signed |
432 |
2022-03-25 15:49 |
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. |
2022-03-25 |
Marvin L Ney |
marvin@paramountems.com |
Peosta |
Dubuque |
IA |
Brenda Weatherwax |
Becky Schmelzer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Maria Ney |
maria@neytrucking.com |
President |
Peosta |
Dubuque |
IA |
Brenda Weatherwax |
Becky Schmelzer |
Signed |
433 |
2022-03-27 15:30 |
Anonymous (not verified) |
208.126.206.146 |
J B Engraving |
206 4th street East Newhall , Iowa 52315 |
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. |
2022-03-27 |
John Lauterwasser |
engravingjb@gmail.com |
Newhall |
Benton |
Iowa |
Lisa Jane Meeks |
Brandon Lauterwasser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LC Anderson |
lbandins@southslope.net |
N/A |
Newhall |
Benton |
Iowa |
Lisa Jane Meeks |
Brandon Lauterwasser |
Signed |
434 |
2022-03-27 15:30 |
Anonymous (not verified) |
208.126.206.146 |
J B Engraving |
206 4th street East Newhall , Iowa 52315 |
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. |
2022-03-27 |
John Lauterwasser |
engravingjb@gmail.com |
Newhall |
Benton |
Iowa |
Lisa Jane Meeks |
Brandon Lauterwasser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LC Anderson |
lbandins@southslope.net |
N/A |
Newhall |
Benton |
Iowa |
Lisa Jane Meeks |
Brandon Lauterwasser |
Signed |
435 |
2022-03-28 07:14 |
Anonymous (not verified) |
75.162.66.125 |
Jenkins Electric LLC |
304 E North St. Prairie City, IA |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-28 |
Colten Jenkins |
colten@jenkins-electric.com |
Prairie City |
Jasper |
Iowa |
Kristin Jenkins |
David Jennings |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Colten Jenkins |
colten@jenkins-electric.com |
Owner |
Prairie City |
Jasper |
Iowa |
Kristin Jenkins |
David Jennings |
Signed |
437 |
2022-03-29 14:03 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise |
101 Ashworth Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-29 |
Mersad Bosnic |
mersadbosnic@yahoo.com |
Urbandale |
Polk |
Iowa |
Mersad Bosnic |
Andy Swanson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andy Swanson |
sanienterprise14@gmail.com |
Director of Operations |
Granger |
Dallas |
Iowa |
Andrew Swanson |
Sandro Tadic |
Signed |
438 |
2022-03-29 16:28 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise |
101 Ashworth Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-03-29 |
Azmir Alic |
ale_boss00@hotmail.com |
Urbandale |
polk |
iowa |
Azmir Alic |
Andrew Swanson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrew Swanson |
sanienterprise14@gmail.com |
Director of Operations |
Granger |
Dallas |
Iowa |
Andrew Swanson |
Sandro Tadic |
Signed |
439 |
2022-03-29 19:23 |
Anonymous (not verified) |
173.215.72.139 |
Vinton Enterprises LLC |
24704 Isbell Lane, Glenwood, IA 51534 |
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. |
2022-03-29 |
Holly Vinton |
vintonfive@hotmail.com |
Glenwood |
Mills |
Iowa |
David Pratt |
Chad MIller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Holly Vinton |
vintonfive@hotmail.com |
owner |
Glenwood |
Mills |
Iowa |
David Pratt |
Chad Miller |
Signed |
440 |
2022-03-29 20:05 |
Anonymous (not verified) |
174.215.228.20 |
Navarro construction |
2825 SE 14th St lot #6 |
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. |
2022-03-29 |
Enrique Navarro |
enriquenavarro887@gmail.com |
Des Moines |
Polk |
IA |
Alondra Navarro |
René Navarro |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Enrique Navarro |
enriquenavarro884@gmail.com |
Owner |
Des moines |
Polk |
IA |
Alondra Navarro |
René Navarro |
Signed |
448 |
2022-04-19 15:15 |
Anonymous (not verified) |
184.80.177.137 |
Andrew Lemke DBA: TAP Fabrication |
27214 218th Street, Earlville, IA 52041 |
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. |
2022-04-08 |
Andrew Lemke |
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 |
441 |
2022-04-11 13:15 |
Anonymous (not verified) |
75.162.175.12 |
Castro construction LLC |
1712 carpenter av desmoines Iowa 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-11 |
Carlos Alberto castro Alcántara |
castrodvxhd@gmail.com |
Estados Unidos |
Iowa |
Desmoines |
Blanca Yadira montes Quiñones |
Maynor Noe padilla bonilla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carlos Alberto castro Alcántara |
castrodvxhd@gmail.com |
Owner |
Estados unidos |
Iowa |
Desmoines |
Blanca Yadira montes Quiñones |
Maynor Noe Padilla Bonilla |
Signed |
442 |
2022-04-11 13:15 |
Anonymous (not verified) |
75.162.175.12 |
Castro construction LLC |
1712 carpenter av desmoines Iowa 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-11 |
Carlos Alberto castro Alcántara |
castrodvxhd@gmail.com |
Estados Unidos |
Iowa |
Desmoines |
Blanca Yadira montes Quiñones |
Maynor Noe padilla bonilla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carlos Alberto castro Alcántara |
castrodvxhd@gmail.com |
Owner |
Estados unidos |
Iowa |
Desmoines |
Blanca Yadira montes Quiñones |
Maynor Noe Padilla Bonilla |
Signed |
443 |
2022-04-11 13:15 |
Anonymous (not verified) |
75.162.175.12 |
Castro construction LLC |
1712 carpenter av desmoines Iowa 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-11 |
Carlos Alberto castro Alcántara |
castrodvxhd@gmail.com |
Estados Unidos |
Iowa |
Desmoines |
Blanca Yadira montes Quiñones |
Maynor Noe padilla bonilla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carlos Alberto castro Alcántara |
castrodvxhd@gmail.com |
Owner |
Estados unidos |
Iowa |
Desmoines |
Blanca Yadira montes Quiñones |
Maynor Noe Padilla Bonilla |
Signed |
444 |
2022-04-14 15:50 |
Anonymous (not verified) |
72.10.21.42 |
Babcock Services Idaho, Inc. |
8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 |
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. |
2022-04-14 |
Carmen Clyde |
CCLYDE@BABCOCKSERVICES.COM |
KENNEWICK |
WA |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CARMEN CLYDE |
CCLYDE@BABCOCKSERVICES.COM |
Secretary |
KENNEWICK |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
445 |
2022-04-14 15:52 |
Anonymous (not verified) |
72.10.21.42 |
Babcock Services Idaho, Inc. |
8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 |
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. |
2022-04-14 |
Keith Myers |
CCLYDE@BABCOCKSERVICES.COM |
KENNEWICK |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CARMEN CLYDE |
CCLYDE@BABCOCKSERVICES.COM |
Secretary |
KENNEWICK |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
446 |
2022-04-14 15:54 |
Anonymous (not verified) |
72.10.21.42 |
Babcock Services Idaho, Inc. |
8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 |
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. |
2022-04-14 |
Phil Gallagher |
pgallagher@babcockservices.com |
Richland |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CARMEN CLYDE |
CCLYDE@BABCOCKSERVICES.COM |
Secretary |
KENNEWICK |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
447 |
2022-04-15 16:59 |
Anonymous (not verified) |
166.181.87.86 |
STEVE MORRISON TRUCKING |
P.O. Box 66 Danville,IA 52623 |
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. |
2022-04-15 |
Stephen D. Morrison |
sdmt13@gmail.com |
Danville |
Des Moines |
IA |
Ellie Miller |
Janice Helt |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Stephen Dwight Morrison |
sdmt13@gmail.com |
Owner |
Danville |
Des Moines |
IA |
Ellie Miller |
Janice Helt |
Signed |
449 |
2022-04-19 21:09 |
Anonymous (not verified) |
172.86.44.178 |
Holtkamp Transportation LLC |
2282 Windmill Way, West Point, IA 52656 |
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. |
2022-04-19 |
Les Holtkamp |
les@holtkamplogistics.com |
West Point |
Lee |
Iowa |
Ben Hogan |
Tina Holtkamp |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Ben Hogan |
ben@truserveins.com |
Insurance Agent |
Readlyn |
Bremer |
Iowa |
Jaci Hogan |
Nicole Barnes |
Signed |
450 |
2022-04-20 13:42 |
Anonymous (not verified) |
96.85.81.137 |
D&K Harvesting Inc. |
P.o Box 1347 LaBelle Fl 33975 |
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. |
2022-04-20 |
James Larry Marsh Jr |
larrym3041@aol.com |
Fort myers |
Lee |
Florida |
Anita Coronado |
Christy Pequeno |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
James Larry Marsh Jr |
larrym3041@aol.com |
Owner |
Fort myers |
Lee |
Florida |
Anita Coronado |
Christy Puequeno |
Signed |