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Rejection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Corporation: Address of Corporation Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Statement Agreement: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Agreement: Alternative Selection: Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Corporation of Authorized Agent: City of Residence: County of Residence: State: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
822 2023-11-20 09:43 Anonymous (not verified) 94.188.207.223 Lifeson LLC 303 6th Ave Coralville IA 52241 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. 2023-11-14 Scott Parshall scott@lifeson.com Coralville Johnson Iowa Samantha Mlavsky Pamela Mahon Signed (1) The corporation rejects the employers’ liability coverage. Scott Parshall scott@lifeson.com member Coralville Johnson Iowa Samantha Mlavsky Pamela Mahon Signed
54 2020-04-03 19:30 Anonymous (not verified) 173.25.134.162 Luke Laxton 1502 guthrie ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-03 Luke Laxton kyekingstonl@gmail.com Des Moines Iowa United States Omer Okic Nicholas weber Signed (1) The corporation rejects the employers’ liability coverage. Luke Laxton kyekingstonl@gmail.com Owner Des Moines Iowa United States Omer Okic Nicholas weber Signed
166 2021-01-21 08:52 Anonymous (not verified) 66.102.212.10 English River Transport, Inc. 2015 Highway 22, Kalona, IA 52247 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. 2021-01-13 James A Yoder fisheria@kctc.net Kalona Washington IA Christian Swartzentruber Judy Showalter Signed (1) The corporation rejects the employers’ liability coverage. James A Yoder christian@fisherins.com President Kalona Washington IA Christian Swartzentruber Judy Showalter Signed
278 2021-06-18 11:37 Anonymous (not verified) 75.162.29.203 Digital Agronomy, LLC 4270 199th St. Ames, IA 50014 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2021-06-17 Patrick T. Murphy ptmurphy82@gmail.com Ames Story Iowa David Cory Mary Cory Signed (2) The corporation declines to reject the employers’ liability coverage. Patrick T. Murphy ptmurphy82@gmail.com Owner Ames Story Iowa David Cory Mary Cory Signed
390 2022-01-20 11:06 Anonymous (not verified) 162.246.237.102 High Pointe Construction 903 Summerset pl Indianola iowa 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. 2022-01-19 Andrey Shabak shabakandre@gmail.com indianola warren Iowa Inna zayets bob Signed (1) The corporation rejects the employers’ liability coverage. Andrey shabak shabakandre@gmail.com owner indianola warren ia inna zayets bob Signed
502 2022-06-24 12:15 Anonymous (not verified) 173.31.148.43 HISTORIC ARNOLDS PARK INC 37 LAKE ST ARNOLDS PARK, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-06-24 GARY RAY GARYJRAY70@GMAIL.COM SPIRIT LAKE DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. JON PAUSLEY JON@ARNOLDSPARK.COM CEO MILFORD DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
917 2024-03-11 12:51 Anonymous (not verified) 94.188.205.168 Hernandez Construction KD 119 W Maxson 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. 2024-03-11 Juan Santiago Hernandez chagodoki74@gmail.com West Liberty Muscatine Iowa Kevin Kofron Kiara Hernandez Signed (1) The corporation rejects the employers’ liability coverage. Juan Santiago Hernandez chagodoki74@gmail.com Owner West Liberty Muscatine Iowa Kevin Kofron Kiara Hernandez Signed
614 2023-02-28 07:24 Anonymous (not verified) 94.188.207.229 River City Transport, Inc 131 West 10th st, 4th floor 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. 2023-02-28 Brian Brewer brian@rivercitylogistics.net Sparks NV United States Matthew Gazzola Jacob Shireman Signed (1) The corporation rejects the employers’ liability coverage. Brian Brewer brian@rivercitylogistics.net Vice President Sparks NV United States Matthew Gazzola Jacob Shireman Signed
726 2023-08-02 17:30 Anonymous (not verified) 94.188.205.169 Furever Friends of Appanoose, Inc 19507 Hwy 2, Centerville, Iowa 52544 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. 2023-08-02 Clint Raymond Housh clinthoush@lockridgeinc.com Centerville Appanoose Iowa Brian Seeman Drew Power Signed (1) The corporation rejects the employers’ liability coverage. Clint Housh clinthoush@lockridgeinc.com Vice President Centerville Appanoose Iowa Brian Seeman Drew Power Signed
838 2023-12-14 08:57 Anonymous (not verified) 94.188.207.223 Chuck Amling 807 Main Street, Garber IA 52048 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. 2023-12-14 Chuck Amling mitzi@bruggemanlumber.com Garber IA United States Michelle Hoeger Roger Gibbs Signed (1) The corporation rejects the employers’ liability coverage. Chuck Amling mitzi@bruggemanlumber.com Self Garber Clayton United States Michelle Hoeger Roger Gibbs Signed
70 2020-04-21 10:29 Anonymous (not verified) 173.24.181.211 Mr. Drain Man LLC 607 36th Street, Spirit Lake IA 51360 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-21 Jan Coon jennifer@walkerinsuranceia.com Spirit Lake Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Mr Drain Man LLC jennifer@walkerinsuranceia.com Member Spirit Lake Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
515 2022-07-19 10:06 Anonymous (not verified) 184.80.177.137 Mom Clean, LLC 4 East 3rd 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. 2022-07-18 Morgan Lahr dparsons@english-insurance.com Dyersville Delaware IA Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com self Dyersville Dubuque IA Derrick Parsons Joyce Heims Signed
930 2024-03-21 20:44 Anonymous (not verified) 94.188.207.229 Southeast Iowa Precision Painting 714 Lincoln St Ainsworth IA 52201 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-21 Kirby Jay Shetler kirbyshetler@gmail.com Ainsworth Washington Iowa Kirby Shetler Demi Shetler Signed (1) The corporation rejects the employers’ liability coverage. Southeast Iowa Precision Painting kirbyshetler@gmail.com Owner Ainsworth Washington Iowa Kirby Shetler Demi Shetler Signed
627 2023-03-17 06:48 Anonymous (not verified) 94.188.207.229 Hearing Health Care, LLC 2519 South 16th Street Council Bluffs, IA 51501 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. 2023-03-17 Melissa Ann Knoell melissaknoell@yahoo.com Council Bluffs Pottowattomi Iowa Bruce Carol Johnk Marcelyn Maureen Johnk Signed (1) The corporation rejects the employers’ liability coverage. Melissa Ann Knoell melissaknoell@yahoo.com Self Council Bluffs Pottawattomi Iowa Bruce Carol Johnk Marcelyn Maureen Johnk Signed
739 2023-08-11 18:02 Anonymous (not verified) 94.188.205.176 Frontline Roofing & Construction LLC 310 W Gilbert Dr I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2023-08-10 Verónica Santos FrontlineR-C@outlook.com Evansdale BlackHawk County IA Angela Hernandez Kevi Hernandez Signed (2) The corporation declines to reject the employers’ liability coverage. Veronica Santos angelasermeno@gmail.com Owner Evansdale BlackHawk IA Angela Hernandez Signed
851 2024-01-14 15:40 Anonymous (not verified) 94.188.205.169 B St. Construction + Design, Inc. 16 Southwest 42nd 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. 2024-01-13 Emily Renze-Crouch emily@bstdesigner.com Des Moines Iowa United States Jodi Essex Linda K Renze Signed (1) The corporation rejects the employers’ liability coverage. Emily Renze-Crouch emily@bstdesigner.com Vice President / CFO Des Moines IA United States Jodi Essex Linda K Renze Signed
83 2020-05-20 12:34 Anonymous (not verified) 108.171.131.188 North Iowa Custom Seamless Guttering, Inc PO Box 512, 1300 2nd Ave S, Clear Lake, Iowa 50428 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-05-20 Keith E Main keithmaincsg@hotmail.com Clear Lake Cerro Gordo Iowa Lloyd L Heinselman Diane K Harrington Signed (1) The corporation rejects the employers’ liability coverage. Keith E Main keithmaincsg@hotmail.com President Clear Lake Cerro Gordo Iowa Lloyd L Heinselman Diane K Harrington Signed
195 2021-03-02 16:29 Anonymous (not verified) 173.29.156.163 Certified drywall 329 e.11th st Davenport, Iowa 52803 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-02 Thomas wells mikeparry783@gmail.com Davenport Scott Iowa Chyna rose pena Natalie parry Signed (2) The corporation declines to reject the employers’ liability coverage. Thomas wells mikeparry783@gmail.com Self Davenport Scott Iowa Chyna rose pena Natalie parry 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
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
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
946 2024-04-04 11:53 Anonymous (not verified) 94.188.205.169 Soto Stone LLC 1071 Mansfield dr waukee iowa 50263 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2024-04-04 Yesser Lenin Juarez Soto sotostonellc95@gmail.com Waukee DALLAS Iowa Ashley Marie Francisco Vincent Alexander Flores Signed (2) The corporation declines to reject the employers’ liability coverage. Yesser Lenin Juarez Soto sotostonellc95@gmail.com Self Waukee Dallas Iowa Ashley Marie Francisco Vincent Alexander Flores Signed
643 2023-03-30 09:58 Anonymous (not verified) 94.188.205.175 Adamantine Spine Moving 2726 Independence Rd., Iowa City, IA 52240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-30 Emily Wallace emily.wallace@spinemoving.com Des Moines Polk Iowa John Wallace Ashley Koch Signed (1) The corporation rejects the employers’ liability coverage. Ashley Koch ashley.koch@spinemoving.com Human Resources Manager West Des Moines Polk Iowa John Wallace Taylor Roth Signed
755 2023-08-25 11:34 Anonymous (not verified) 94.188.205.169 Paralax Corporation dba Beck Electric 8646 103rd Ave Indianola Iowa 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. 2023-08-25 Jonathan Beck jon@beck-electric.com Indianola Warren Iowa Stephanie Watkins-Beck Michael Beck Signed (1) The corporation rejects the employers’ liability coverage. Jonathan Beck jon@beck-electric.com Owner Indianola Warren Iowa Stephanie Watkins-Beck Michael Beck Signed
867 2024-01-24 15:04 Anonymous (not verified) 94.188.207.227 Shook Handyman 2415 Plum Creek Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-24 Nolan Shook office@shookhandyman.com Sioux City Woodbury IA McKenna Warner Jessica Shook Signed (1) The corporation rejects the employers’ liability coverage. Susan Geist sgeist@paychex.com Paychex Insurance Agency Inc Rochester Monroe NY Nolan Shook McKenna Warner Signed
99 2020-07-12 13:29 Anonymous (not verified) 207.32.58.202 Subject Enterprise, Inc. 165 210th St Wesley, IA 50483 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-07-12 Coda Subject subjectenterprise@gmail.com Britt Hancock IA Keri Byom Steve Schlichting Signed (1) The corporation rejects the employers’ liability coverage. Coda Subject subjectenterprise@gmail.com Owner Britt Hancock IA Keri Byom Steve Schlichting Signed
211 2021-03-25 09:10 Anonymous (not verified) 204.155.61.217 The New Leaf Co 1095 Oakdale Ave, St Paul, MN 55118 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. 2021-03-02 Michael Hernandaz liveabovethecloudz@gmail.com St Paul Dakota MN DocuSign Ashley Kraft Signed (1) The corporation rejects the employers’ liability coverage. Michael Hernandaz liveabovethecloudz@gmail.com Ower St Paul Dakota mn DocuSign Ashley Kraft 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
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
547 2022-09-29 09:04 Anonymous (not verified) 208.126.212.128 City of Leland 316 Walnut St., PO Box 127, Leland, IA 50453 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. 2022-09-29 Ken Steil leland@wctatel.net Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed (1) The corporation rejects the employers’ liability coverage. Dawn Arispe leland@wctatel.net City of Leland City Clerk Leland Winnebago Iowa Roger Torkelson Kelly Bendickson Signed
962 2024-04-26 08:46 Anonymous (not verified) 94.188.207.225 Gilbert Construction 3174 Hwy F48 West Newton, Iowa 50208 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-26 Christian Gilbert christian.gilbert14@gmail.com Newton Jasper Iowa Leslie Gilbert Shane Gilbert Signed (1) The corporation rejects the employers’ liability coverage. Christian Gilbert christian.gilbert14@gmail.com worker Altoona polk iowa Leslie Gilbert Shane Gilbert Signed
659 2023-04-21 13:58 Anonymous (not verified) 94.188.205.168 Streamline Plumbing LLC 1513 Nw 8th St Grimes, IA 50111 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2023-04-21 Benjamin Molloy slplumbing.llc@gmail.com Grimes IA United States Christine Darnell Steven Perona Signed (2) The corporation declines to reject the employers’ liability coverage. Benjamin Molloy slplumbing.llc@gmail.com owner Grimes IA United States Christine Darnell Steven Perona Signed
771 2023-09-17 13:33 Anonymous (not verified) 94.188.205.176 Apex Landlord Services LLC 429 Shetland Dr NW, Cedar Rapids, IA 52405 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. 2023-09-17 Benjamin Walhood info@apexlandlordservices.com Cedar Rapids Linn Iowa Justin Goebel Jennifer Goebel Signed (1) The corporation rejects the employers’ liability coverage. Benjamin Walhood info@apexlandlordservices.com Managing Member Cedar Rapids Linn Iowa Justin Goebel Jennifer Goebel Signed
883 2024-02-05 11:29 Anonymous (not verified) 94.188.205.175 Nex Level Moving LLC 5634 Deerwood ST SW cedar rapids iowa 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-05 Robert Sanders Sandersrob101300@gmail.com Cedar Rapids Linn Iowa n/a n/a Signed (1) The corporation rejects the employers’ liability coverage. Robert Sanders Sandersrob101300@gmail.com self cedar rapids linn iowa n/a n/a Signed
115 2020-09-08 09:48 Anonymous (not verified) 184.80.177.137 Beyond Builders LLC 206 Culver Road NE, Hopkinton, IA 52237 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-08 John Eiben ginger_bread_man@msn.com HOPKINTON Delaware IA Derrick Parsons Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. John Eiben ginger_bread_man@msn.com Owner Hopkinton Delaware Iowa Derrick Parsons Derrick Parsons Signed
227 2021-04-02 09:58 Anonymous (not verified) 207.177.7.191 GOETTSCH DISPATCH INC 200 MAIN ST GALVA, IA 51020 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. 2021-03-15 ANDREW GOETTSCH andygoettsch@gmail.com Galva Ida Iowa Kristy Dewey Terri Ullrich Signed (1) The corporation rejects the employers’ liability coverage. Andrew Goettsch andygoettsch@gmail.com President Galva Ida Iowa Kristy Dewey Terri Ullrich Signed
339 2021-09-29 16:59 Anonymous (not verified) 69.57.16.37 MC5 CONSTRUCTION INC 1186 TEXAS AVE, LU VERNE, IOWA 50560 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. 2021-03-18 JOSEPH MCDERMOTT joe.mc5construction@gmail.com LU VERNE HUMBOLDT IOWA NICHOLAS GARMAN ANGELA GARMAN Signed (1) The corporation rejects the employers’ liability coverage. JOSEPH MCDERMOTT joe.mc5construction@gmail.com OWNER LU VERNE HUMBOLDT IOWA NICHOLAS GARMAN ANGELA GARMAN Signed
451 2022-04-22 16:06 Anonymous (not verified) 75.63.172.134 Tempus Builders, Inc. 4331 Valley Ridge 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. 2022-04-22 Scott Cooper scott@tempusbuilders.com Dallas TX United States Phil Sheumaker Cristen Cooper Signed (1) The corporation rejects the employers’ liability coverage. Scott Cooper scott@tempusbuilders.com President Dallas TX United States James Buckley Phil Sheumaker Signed
563 2022-11-09 10:28 Anonymous (not verified) 199.168.243.195 Mensingers Aquatic Resources, Inc. 2119 Oak Trail Drive 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. 2022-11-09 Jeff Mensinger jeffrey.mensinger@hdrinc.com Camanche ia United States Cody Mensinger Jeremiah Haas Signed (1) The corporation rejects the employers’ liability coverage. Jeff Mensinger jeffrey.mensinger@hdrinc.com President Camanche ia United States Cody Mensinger Jeremiah Haas Signed
978 2024-05-08 13:47 Anonymous (not verified) 94.188.205.174 Meridian Logistics, LLC 5249 N Park Pl NE, Unit #2060, Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-07 Abigail Matthews almsolutions2021@gmail.com Chicago Cook IL Gayle Matteson Jane Calvert Signed (2) The corporation declines to reject the employers’ liability coverage. Abigail Matthews almsolutions2021@gmail.com Owner Chicago Cook IL Gayle Matteson Jane Calvert Signed
675 2023-05-24 07:55 Anonymous (not verified) 94.188.207.223 Sierra Roofing 401 W 15th Street West Liberty, IA 52776 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. 2023-05-24 Abraham Granjeno Sierra sierraroofing@gmail.com West Liberty Muscatine Iowa Cody Thorpe Claudia Venable Signed (1) The corporation rejects the employers’ liability coverage. Abraham Granjeno Sierra sierraroofing@gmail.com Owner/Self West Liberty Muscatine Iowa Cody Thorpe Claudia Venable Signed
787 2023-10-16 07:30 Anonymous (not verified) 94.188.207.223 Aurora Aesthetics and Functional Medicine LLC 713 1st Ave NW I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-04 Meagan Mclaughlin Aurorafunctionalmed@gmail.com Mount Vernon IA United States Stephanie Friess Michael Friess Signed (1) The corporation rejects the employers’ liability coverage. Michael Friess Aurorafunctionalmed@gmail.com business manager Mount Vernon Iowa United States Meagan Mclaughlin Stephanie Friess Signed
19 2019-12-16 14:04 Anonymous (not verified) 206.80.132.15 Cresco Family Dentistry P.C. 210 N Elm St Cresco, IA 52136 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-12-16 Shirlee J Haw cfdentistry@iowatelecom.net Cresco Howard Iowa Don Dietzenbach Kim Holmes Signed (1) The corporation rejects the employers’ liability coverage. Jeffrey K Haw cfdentistry@iowatelecom.net President Cresco Howard Iowa Don Dietzenbach Kim Holmes Signed
131 2020-11-03 10:26 Anonymous (not verified) 207.32.1.185 Little Bison Childcare Center 404 2nd ST NW Buffalo Center, IA. 50424 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-03 Megan C Holland megzholland@live.com Buffalo Center Winnebago Iowa Nicholas D Holland Emily J Angstman Signed (1) The corporation rejects the employers’ liability coverage. Megan C Holland megzholland@live.com Vice President Buffalo Center Winnebago Iowa Nicholas D Holland Emily J Angstman Signed
243 2021-04-21 13:29 Anonymous (not verified) 198.14.211.149 Centerville Greenhouses 418 N. 5th 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. 2021-04-21 Peter Michael Lind peter@centervillegreenhouses.com Centerville IA United States John Douglas Hurley Dennis James Peters Signed (1) The corporation rejects the employers’ liability coverage. Alexander Joseph Lind alex@centervillegreenhouses.com Vice President Centerville IA United States John Douglas Hurley Dennis James Peters Signed
355 2021-11-05 15:04 Anonymous (not verified) 209.252.172.87 S&S Window Treatments Inc. 2555 Hwy 1 SW, Iowa City, IA 52240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-11-20 Joshua Yoder installation@bachmeiercarpetone.com Iowa City Johnson Iowa Heather Howell Sarah Coberley Signed (1) The corporation rejects the employers’ liability coverage. Joshua Yoder installation@bachmeiercarpetone.com Owner Iowa City Johnson Iowa Sarah Coberley Heather Howell Signed
467 2022-05-09 10:54 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. 2022-05-09 Safet Derguti safetigo@hotmail.com Des Moines Polk Iowa Andrew Swanson Sandro Tadic 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
579 2022-12-07 14:37 Anonymous (not verified) 96.31.1.206 IGL RENTAL LLC PO BOX 317 ARNOLDS PARK IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-25 CHAD JONES STAYBOJI@GMAIL.COM ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. CHAD JONES STAYBOJI@GMAIL.COM MEMBER ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
691 2023-06-19 07:43 Anonymous (not verified) 94.188.207.228 Saul Carreras-Barron 2529 E Walnut Street Des Moines, 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. 2023-06-19 Saul Carreras-Barron saulcarreas@gmail.com Des Moines Polk Iowa Jesus Carreras Maria Barron Signed (1) The corporation rejects the employers’ liability coverage. Saul Carreras-Barron saulcarreas@gmail.com Owner Des Moines Polk Iowa Jesus Carreras Maria Barron Signed
803 2023-10-25 08:37 Anonymous (not verified) 94.188.205.166 CEM Businesses LLC 608 Evergreen Cir NW Bondurant, IA 50035 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. 2023-10-25 Ryan Canales ryancanales44@gmail.com West Des Moines Polk Iowa Raelynn Aicher Cameron VanBuren Signed (2) The corporation declines to reject the employers’ liability coverage. Dane McDonald dane.mcdonald@stellar-solar.net Self Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed