644 |
2023-03-31 08:47 |
Anonymous (not verified) |
94.188.205.175 |
HDEZ, LLC |
7500 Bloomfield Rd, Lot 91, Des Moines, IA 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-31 |
Antonio Rosales |
tonyh873@gmail.com |
Des Moines |
Polk |
Iowa |
Ronald Barton |
Scott Grimm |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Antonio Rosales |
tonyh873@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Ronald Barton |
Scott Grimm |
Signed |
904 |
2024-02-28 06:52 |
Anonymous (not verified) |
94.188.205.167 |
Monarca General Builders LLC. |
551 Martin Rd 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. |
2023-12-28 |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
President |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
905 |
2024-02-28 11:47 |
Anonymous (not verified) |
94.188.207.228 |
Monarca General Builders LLC |
551 Martin Rd 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. |
2024-01-01 |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Presidente |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
157 |
2021-01-06 15:53 |
Anonymous (not verified) |
216.81.153.249 |
Al's Inc DWB CW&T |
1509 Richland Drive, Storm Lake, IA 5058 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-29 |
April Coleman |
NONE@GMAIL.COM |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
April Coleman |
None@gmail.com |
Owner |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
526 |
2022-08-17 11:16 |
Anonymous (not verified) |
173.27.233.86 |
Bradens Roofing and Construction Llc |
2450 Hart Avenue |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-08-17 |
Arsenio Vargas Velazquez |
avargas409@gmail.com |
Des Moines |
polk |
Iowa |
Julissa Dionicio |
Jennifer Dionicio |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Arsenio Vargas Velazquez |
avargas409@gmail.com |
owner |
Des Moines |
Polk |
Iowa |
Julissa Dionicio |
Jennifer Dionicio |
Signed |
372 |
2021-12-09 14:17 |
Anonymous (not verified) |
204.155.61.217 |
Buena Vista Auto Sales Inc |
1030 Lake Ave, Storm Lake, IA 50588 |
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. |
2021-12-09 |
Arturo Lozano |
bvusedcars@siouxland.com |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Michelle Munoz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Arturo Lozano |
bvusedcars@siouxland.com |
Owner |
storm Lake |
Buena Vista |
IA |
Jared Brashears |
Michelle Munoz |
Signed |
845 |
2024-01-02 09:03 |
Anonymous (not verified) |
94.188.205.169 |
American Tree Service LLC |
416 S Kiel Street, Holstein, IA 51025 |
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. |
2024-01-02 |
Austin Thevenot |
americantreeservice03@gmail.com |
Holstein |
Ida |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Austin Thevenot |
americantreeservice03@gmail.com |
Owner |
Holstein |
Ida |
Iowa |
Jared Brashears |
Katie Gunkelman |
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 |
982 |
2024-05-10 19:06 |
Anonymous (not verified) |
94.188.207.228 |
Revella Salon and Spa |
509 Second St Ida Grove, IA 51445 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-10 |
Bailey Roeder |
roeder428@gmail.com |
Ida Grove |
Ida |
Iowa |
Dalton Hemer |
Fina Roeder |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bailey Roeder |
roeder428@gmail.com |
Myself |
Ida Grove |
Ida |
Iowa |
Dalton Hemer |
Fina Roeder |
Signed |
784 |
2023-10-09 13:09 |
Anonymous (not verified) |
94.188.205.177 |
SEHIC G&S LLC |
4201 62nd st apt 4 Urbandale Iowa 50322 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-09 |
Bajro Sehic |
kalesija20@gmail.com |
Urbandale |
Polk |
Iowa |
Bajro sehic |
Bajro sehic |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bajro sehic |
kalesija20@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
Bajro sehic |
Bajro Sehic |
Signed |
477 |
2022-05-19 11:49 |
Anonymous (not verified) |
172.86.13.54 |
BOLT HOLDINGS Inc. and Holt Precision dba Holt Bladeworks and Holt Kinetic Solutions |
3230 N. Center Point Rd Unit 204, Marion, IA 52302 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-19 |
Ben Congleton |
Ben@holtkineticsolutions.com |
Cedar Rapids |
Linn |
Iowa |
Lisa Gleason |
Angey Holt |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Gleason |
Lisa@holtkineticsolutions.com |
General Manager |
Marion |
Linn |
Iowa |
Lisa Gleason |
Danielle Congleton |
Signed |
393 |
2022-01-26 16:35 |
Anonymous (not verified) |
216.51.137.244 |
Metal Works, Inc. |
1015 32nd Ave W, Spencer, IA 51301 |
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. |
2022-01-01 |
Ben Nystrom |
ffernandez@thamsagency.com |
Spencer |
Clay |
Iowa |
Phil Ramstack |
Francia Fernandez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ben Nystrom |
ffernandez@thamsagency.com |
Owner |
Spencer |
Clay |
Iowa |
Philp Ramstack |
Francia Fernandez |
Signed |
685 |
2023-06-15 12:30 |
Anonymous (not verified) |
94.188.205.168 |
Des Moines Marble & Mantel Co. Inc. |
1507 Ohio Street Des Moines, IA 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. |
2023-06-15 |
Benjamin Campos Rojas |
caya05rojas@gmail.com |
Des Moines |
Polk county |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mario DeMarco |
sandyatdmmarble@aol.com |
Owner |
Des Moines |
Polk County |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
687 |
2023-06-16 07:59 |
Anonymous (not verified) |
94.188.207.230 |
Benjamin Campos Rojas |
4024 52nd Street Des Moines, Iowa 50310 |
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. |
2023-06-16 |
Benjamin Campos Rojas |
caya05rojas@gmail.com |
Des Moines |
Polk |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Benjamin Campos Rojas |
caya05rojas@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
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 |
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 |
630 |
2023-03-21 21:32 |
Anonymous (not verified) |
94.188.205.169 |
S & O Builders, LLC |
201 NW 10th Circle, 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. |
(1) I reject the employers’ liability coverage. |
2023-03-21 |
Benjamin Olson |
sandobuilders@gmail.com |
Grimes |
IA |
IA |
Brad Fasse |
Nate Estes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Benjamin Olson |
sandobuilders@gmail.com |
Co-Owner |
Grimes |
IA |
IA |
Brad Fasse |
Nate Estes |
Signed |
394 |
2022-01-27 12:29 |
Anonymous (not verified) |
72.255.65.83 |
Rodgers’ Building & Remodeling Inc |
1003 NW 37th 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. |
2021-01-28 |
Benjamin Rodgers |
btrdsm18@gmail.com |
Ankeny |
Polk |
Iowa |
Mary Rodgers |
Larry Joel |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mary Rodgers |
steff.m2096@yahoo.com |
President |
Ankeny |
Polk |
Iowa |
Ben Rodgers |
Larry Joel |
Signed |
146 |
2020-12-22 08:48 |
Anonymous (not verified) |
207.155.115.120 |
Kafer Lawn Care |
206 frentress dr Farley, IA 52046 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-22 |
Benjamin Terry Hayes |
benhayes1800@gmail.com |
Epworth |
Dubuque |
IA |
Adam Kafer |
Jeffery Sisler |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Benjamin Terry Hayes |
benhayes1800@gmail.com |
Owner |
Epworth |
Dubuque |
IA |
Adam Kafer |
Jeffery Sisler |
Signed |
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 |
107 |
2020-08-04 13:42 |
Anonymous (not verified) |
97.64.131.90 |
BNR Construction INC |
210 4th St Orient, IA 50858 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-08-04 |
Bennie Shinn |
bnrconstllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
111 |
2020-08-25 14:37 |
Anonymous (not verified) |
204.155.61.217 |
BNR Construction INC |
210 4th St Orient,Ia 50858 |
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. |
2020-07-15 |
Bennie Shinn |
bnrconstructllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstructllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
112 |
2020-08-26 10:18 |
Anonymous (not verified) |
97.64.131.90 |
BNR Construction INC |
210 4th St Orient, IA 50858 |
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. |
2020-07-15 |
Bennie Shinn |
bnrconstllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
318 |
2021-08-23 11:00 |
Anonymous (not verified) |
216.51.164.69 |
Z Homes and Realty Inc |
1324 3rd Ave SE Sioux Center IA 51250 |
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. |
2021-05-19 |
Beverly Zwart |
mbzwrt@mtcnet.net |
Sioux Center |
Sioux |
IA |
Lisa Dykstra |
Blake Kruger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Beverly Zwart |
mbzwrt@mtcnet.net |
Owner |
Sioux Center |
Sioux |
IA |
Lisa Dykstra |
Blake Kruger |
Signed |
329 |
2021-09-08 10:18 |
Anonymous (not verified) |
206.80.128.71 |
H F Corporation |
105 E Oskaloosa Pella, IA 50219 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-08 |
Bharat Patel |
super8pella@gmail.com |
Pella |
Marion |
Iowa |
Mark Chambers |
Jim Wessels |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeremy Rogstad |
jeremy@jeremyrogstad.com |
State Farm Agent |
Iowa |
Floyd |
Iowa |
Mark Chambers |
Jim Wessels |
Signed |
482 |
2022-06-02 08:25 |
Anonymous (not verified) |
173.18.193.51 |
Wever Fire Association |
1692 354th Avenue, Wever, Iowa 52658 |
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. |
2022-05-24 |
Bill Brookhiser |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill Brookhiser |
judy@fullenkampins.com |
Board Member |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
337 |
2021-09-16 21:28 |
Anonymous (not verified) |
173.17.8.56 |
Hutch's Parking Lot Sweeping Inc. |
5235 Jennifer Dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-16 |
Bill E Hutchinson |
btnwhutch@aol.com |
Pleasant Hill |
Iowa |
Iowa |
Tracy Hutchinson |
Nic Hutchinson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill E Hutchinson |
btnwhutch@aol.com |
Same |
Pleasant Hill |
Iowa |
Iowa |
Tracy Hutchinson |
Nic Hutchinson |
Signed |
172 |
2021-01-26 19:02 |
Anonymous (not verified) |
173.17.8.56 |
Hutch's Parking Lot Sweeping |
5235 JENNIFER DR |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-26 |
Bill HUTCHINSON |
btnwhutch@aol.com |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
WHITNIE HUTCHINSON |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill HUTCHINSON |
btnwhutch@aol.com |
Self |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
WHITNIE HUTCHINSON |
Signed |
965 |
2024-04-30 10:47 |
Anonymous (not verified) |
94.188.205.177 |
Billy Dudock |
148818 Argo Fay 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. |
2024-04-30 |
Billy Dudock |
mitzi@bruggemanlumber.com |
Thompson |
Carroll |
IL |
Roger Gibbs |
Mitzi Hoeger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Billy Dudock |
mitzi@bruggemanlumber.com |
Self |
Thompson |
Carroll |
Il |
Roger Gibbs |
Mitzi Hoeger |
Signed |
106 |
2020-07-27 12:12 |
Anonymous (not verified) |
206.125.132.254 |
Pacos Roofing Inc |
837 Lynkaylee Dr Waterloo, IA 50701 |
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. |
2020-07-27 |
Blanca Garcia |
Pacosroofing@outlook.com |
Waterloo |
Black Hawk |
Iowa |
Kaitlin Schepers |
Sarah Whalen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Blanca Garcia |
Pacosroofing@outlook.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Kaitlin Schepers |
Sarah Whalen |
Signed |
804 |
2023-10-31 13:04 |
Anonymous (not verified) |
94.188.207.226 |
NeX Level Restoration LLC |
314 8th ST 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. |
2023-10-31 |
Bobby Caldwell SR |
blc5000@msn.com |
Cedar Rapids |
Linn |
IA |
Adam Feldmann |
Tarin Tanner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bobby Caldwell |
blc5000@msn.com |
Self |
Cedar Rapids |
Linn |
IA |
Adam Feldmann |
Tarin Tanner |
Signed |
562 |
2022-11-04 10:32 |
Anonymous (not verified) |
98.159.123.124 |
Alli-Center |
555 Cameron Way Unit 2 North Liberty Iowa 52317 |
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. |
2022-11-04 |
Bonnie Seely |
bseely4@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Jonah C Seely |
Hannah Seely |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bonnie Seely |
bseely4@gmail.com |
Owner/Self |
Cedar Rapids |
Linn |
Iowa |
Jonah Seely |
Hannah Seely |
Signed |
656 |
2023-04-19 10:46 |
Anonymous (not verified) |
94.188.205.174 |
Brad Anthony Logging LLC |
307 Commercial St, Strawberry Point IA 52076 |
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. |
2023-04-18 |
Brad Anthony |
banthony6487@gmail.com |
Strawberry Point |
Clayton |
Iowa |
Roger Gibbs |
Mitzi Hoeger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Anthony |
banthony6487@gmail.com |
Self |
Strawberry Point |
Clayton |
Iowa |
Mitzi Hoeger |
Roger Gibbs |
Signed |
204 |
2021-03-08 10:43 |
Anonymous (not verified) |
151.147.196.21 |
Iowa Gold Distributing, Inc. |
600 Iehl Street, Central City, IA 52214 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-02-10 |
Brad Coates |
igdenv@aol.com |
Central City |
Linn |
Iowa |
William Walters |
Jennifer Leinen |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Brad Coates |
igdenv@aol.com |
Director |
Central City |
Linn |
Iowa |
William Walters |
Jennifer Leinen |
Signed |
233 |
2021-04-13 10:35 |
Anonymous (not verified) |
172.83.18.1 |
Skyway Inc |
7030 27th Way, Clear Lake, IA 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. |
2021-03-06 |
Brad Thompson |
mary@skywaypropertyinspections.com |
Clear Lake |
Cerro Gordo |
Iowa |
Becky Plagge |
Deb Otto |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Thompson |
mary@skywaypropertyinspections.com |
Owner |
Clear Lake |
Cerro Gordo |
Iowa |
Becky Plagge |
Deb Otto |
Signed |
245 |
2021-04-22 10:54 |
Anonymous (not verified) |
172.83.18.1 |
Skyway Inc |
7030 27th Way, Clear Lake, IA 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. |
2021-04-22 |
Brad Thompson |
becky@fgains.com |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Thompson |
becky@fgains.com |
Owner |
Clear Lake |
Cerro Gordo |
Iowa |
Debbie Otto |
Paxton Farmer |
Signed |
228 |
2021-04-05 13:06 |
Anonymous (not verified) |
173.18.193.51 |
Houghton Cedar Township Fire Department |
1135 140th Avenue, Salem, Iowa 52649 |
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. |
2021-04-03 |
Brad Vandenberg |
judy@fullenkampins.com |
Donnellson |
Lee |
Iowa |
Judy Moeller |
Shelby Green |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Vandenberg |
judy@fullenkampins.com |
Board Member |
Salem |
Lee |
Iowa |
Judy Moeller |
Shelby Green |
Signed |
764 |
2023-09-10 19:18 |
Anonymous (not verified) |
94.188.205.177 |
Heartland Ultrasonography Group |
1015 Woodland Drive Carlisle, Iowa 50047 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-10 |
Bradley C Curtis |
blc735@msn.com |
Carlisle |
Warren |
Iowa |
Dane Joseph Wright |
Michael Lee Guffey |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley C Curtis |
Heartlandusgroup@outlook.com |
Co-owner llc |
Carlisle |
Warren |
Iowa |
Dane Joseph Wright |
Michael Lee Guffey |
Signed |
966 |
2024-04-30 14:39 |
Anonymous (not verified) |
94.188.207.230 |
Bowman Dozing & Excavating LLC |
218 134th ave Maquoketa, IA 52060 |
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. |
2024-04-30 |
Bradley D Bowman |
dozermann9@hotmail.com |
Maquoketa |
Jackson |
Iowa |
Jennifer Machande |
Mitchell Schaller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley D Bowmann |
dozermann9@hotmail.com |
owner/president |
maquoketa |
Jackson |
iowa |
Jennifer Machande |
Mitch Schaller |
Signed |
862 |
2024-01-22 13:55 |
Anonymous (not verified) |
94.188.207.228 |
Emcubed Enterprises, Inc |
979 40th Ave, Bettendorf, IA 52722 |
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. |
2024-01-22 |
Bradley D Morrison |
brad@riverbendsignworks.com |
Moline |
Rock Island |
IL |
Richard Henning |
Kyle Sebben |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Morrison |
brad@riverbendsignworks.com |
Owner |
Moline |
Rock Island |
IL |
Richard Henning |
Kyle Sebben |
Signed |
844 |
2023-12-29 08:28 |
Anonymous (not verified) |
94.188.207.226 |
Emcubed Enterprises, Inc |
979 40th Ave, Bettendorf, IA 52722 |
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. |
2023-12-29 |
Bradley David Morrison |
brad@riverbendsignworks.com |
Moline |
Rock Island |
IL |
David Rodriguez |
Lisbet Lule |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley David Morrison |
brad@riverbendsignworks.com |
Owner |
Moline |
Rock Island |
IL |
David Rodriguez |
Lisbet Lule |
Signed |
385 |
2022-01-11 08:27 |
Anonymous (not verified) |
173.29.238.103 |
Brilliant All-Seasons Lighting Inc. |
10357 NW 42nd St., Polk City, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-11 |
Bradley Harold Loney |
bloney@live.com |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Katrina Loney |
katrinaloney@outlook.com |
Vice President |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
91 |
2020-06-17 17:47 |
Anonymous (not verified) |
166.182.83.28 |
BJJ Painting Inc |
6940 Rolling Ridge CT SW Cedar Rapids IA 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. |
2020-06-17 |
Bradley Johnson |
brad.johnson@fivestarpainting.com |
Cedar Rapids |
Linn |
Iowa |
Mike McClure |
Tony Gaiffe |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley Johnson |
brad.johnson@fivestarpainting.com |
President |
Cedar Rapids |
Linn |
Iowa |
Mike McClure |
Tony Gaiffe |
Signed |
906 |
2024-02-29 16:16 |
Anonymous (not verified) |
94.188.205.168 |
Bradley K. Gaul Handyman Services |
740 Cedar Valley Road, Tipton, IA 52772 |
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. |
2024-02-29 |
Bradley Keith Gaul |
bjgjal33@aol.com |
Tipton |
Cedar |
Iowa |
Jill Lynette Gaul |
Logan Benjamin Gaul |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley Keith Gaul |
bjgjal33@aol.com |
Self |
Tipton |
Cedar |
Iowa |
Jill Lynette Gaul |
Logan Benjamin Gaul |
Signed |
182 |
2021-02-18 08:52 |
Anonymous (not verified) |
173.18.193.51 |
Freeman Family Farms Inc |
3125 Glasgow Rd Fairfield Iowa 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. |
2021-02-08 |
Bradly Freeman |
jill@fullenkampins.com |
Mt. Pleasant |
Henry |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradly Freeman |
jill@fullenkampins.com |
Treasurer |
Mt Pleasant |
Henry |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
604 |
2023-02-16 16:13 |
Anonymous (not verified) |
94.188.207.226 |
Transcend Mind Body Wellness and Floatation Clinic |
409 Washington Street, Cedar Falls, IA 50613 |
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. |
2023-01-01 |
Brady Huls |
brady.huls@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Morgan Huls |
Ashlyn Henry |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Morgan Huls |
transcendcedarfalls@gmail.com |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
Brady Huls |
Ashlyn Henry |
Signed |
602 |
2023-02-16 16:10 |
Anonymous (not verified) |
94.188.207.228 |
Friday After Work LLC |
2526 Rainbow Drive, Cedar Falls, IA 50613 |
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. |
2023-01-01 |
Brady John Huls |
brady.cve@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Tyler Reynolds |
Joshua Carder |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brent Dunlop |
fawconstruction.ia@gmail.com |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
Tyler Reynolds |
Joshua Carder |
Signed |
518 |
2022-07-21 10:58 |
Anonymous (not verified) |
75.162.31.164 |
Bengard Roofing LLC |
1927 Wethersfield Dr, Norwalk, IA 50211 |
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. |
2022-07-21 |
Brandon Bengard |
bj@bengardroofing.com |
Norwalk |
Warren |
IA |
Rebecca Bengard |
Juhl Bengard |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brandon Bengard |
bj@bengardroofing.com |
Owner |
Norwalk |
Warren |
IA |
Becky Bengard |
Juhl Bengard |
Signed |
842 |
2023-12-18 16:31 |
Anonymous (not verified) |
94.188.205.168 |
Brandon Clement |
3503 South Union 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. |
2023-12-18 |
Brandon Clement |
hawthornhill@paramark.us |
Des Moines |
Polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brandon Clement |
hawthornhill@paramark.us |
none |
Des Moines |
polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
967 |
2024-05-01 06:30 |
Anonymous (not verified) |
94.188.207.224 |
Cael Gulrud |
206 W Main St Calmar, IA, 52132 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-01 |
Brandon Gulrud |
mojopants21@gmail.com |
Waterloo |
Blackhawk |
IA |
Victoria Bacon-Ortiz |
David Gulrud |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cael Gulrud |
gulrud8728@gmail.com |
Owner |
Calmar |
Winneshiek |
IA |
Victoria Bacon-Ortiz |
David Gulrud |
Signed |