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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:
428 2022-03-23 12:00 Anonymous (not verified) 76.76.231.229 Connelly Sanitation Inc 108 S. 14th St. Fairfield IA 52556 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-23 Richard Raymond Vogt connelly.inc@outlook.com Fairfield Jefferson Iowa Mindy Lynn Vogt Chester James Vogt Signed (1) The corporation rejects the employers’ liability coverage. Richard Raymond Vogt connelly.inc@outlook.com Self Fairfield Jefferson Iowa Mindy Lynn Vogt Chester James Vogt Signed
697 2023-06-20 21:56 Anonymous (not verified) 94.188.207.230 Cedar Valley Flooring 1083 150th Plainfield Ia 50666 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. 2023-06-20 michael kASPAR mikekaspar@hotmail.com plainfield IA IOWA RYAN PARCHER JOHN STEENBLOCK Signed (1) The corporation rejects the employers’ liability coverage. MICHAEL d KASPAR mikekaspar@hotmail.com PRESIDENT plainfield BREMMER IOWA JOHN STEENBLOCK RYAN PARCHER Signed
663 2023-05-03 12:53 Anonymous (not verified) 94.188.205.177 Seven Oaks Recreation 1086 222nd Dr., Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-03 Joel Bryan joel@sevenoaksrec.com Ogden Boone United States Anthony Calek Craig Christensen Signed (1) The corporation rejects the employers’ liability coverage. Sara Bryan sara@sevenoaksre.com Director/Vice-President/Secretary Boone Boone United States Anthony Calek Craig Christensen Signed
664 2023-05-03 12:54 Anonymous (not verified) 94.188.205.174 Seven Oaks Recreation 1086 222nd Dr., Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-03 Sara Bryan sara@sevenoaksrec.com Ogden Boone Iowa Anthony Calek Craig Christensen Signed (1) The corporation rejects the employers’ liability coverage. Sara Bryan sara@sevenoaksre.com Director/Vice-President/Secretary Boone Boone United States Anthony Calek Craig Christensen Signed
665 2023-05-03 12:54 Anonymous (not verified) 94.188.205.169 Seven Oaks Recreation 1086 222nd Dr., Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-03 Joel Bryan joel@sevenoaksrec.com Ogden Boone Iowa Anthony Calek Craig Christensen Signed (1) The corporation rejects the employers’ liability coverage. Sara Bryan sara@sevenoaksre.com Director/Vice-President/Secretary Boone Boone United States Anthony Calek Craig Christensen Signed
129 2020-10-30 11:23 Anonymous (not verified) 184.80.177.137 Haberdash Outfitters, Inc. 109 1st Ave East - Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-10-27 Jennifer Recker jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
277 2021-06-17 21:34 Anonymous (not verified) 97.125.98.166 J. Bos Holdings 10925 NE 23rd Ave Mitchellville, IA 50169 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. 2021-06-17 Jeff Bos jeffbos1967@gmail.com Mitchellville Iowa United States Angela Bos Amy Bos Signed (1) The corporation rejects the employers’ liability coverage. Jeff Bos jeffbos1967@gmail.com officer Mitchellville Iowa United States Angela Bos Amy Bos 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
173 2021-01-26 19:29 Anonymous (not verified) 173.17.84.174 Robert Schroeder const. inc 10984 150 th. st. davenport ia. 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-26 ROBERT SCHROEDER r.schroeder@aol.com davenport scott ia. Debra Blaser John Ekin Signed (1) The corporation rejects the employers’ liability coverage. ROBERT SCHROEDER r.schroeder@aol.com President davenport scott ia. Debra Blaser John Ekin Signed
17 2019-12-12 13:20 Anonymous (not verified) 65.126.161.162 Robert J Schroeder Const. Inc. 10984 150th St Davenport, IA 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-12-12 Robert J Schroeder None@none.com Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed (1) The corporation rejects the employers’ liability coverage. Robert J Schroeder None@none.com President Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed
759 2023-08-31 16:11 Anonymous (not verified) 94.188.207.230 Living Free Ministries 11 2nd St NW, Mason City, IA 50401 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. 2023-08-31 Jani Dahlin livingfreeiowa@gmail.com Mason City Cerro Gordo IA Jenny McIntyre Alex Meier Signed (1) The corporation rejects the employers’ liability coverage. Jani Dahlin livingfreeiowa@gmail.com President Mason City Cerro Gordo IA Jenny McIntyre Alex Meier Signed
82 2020-05-18 15:16 Anonymous (not verified) 184.80.177.137 Farmers Best Popcorn, LLC 110 1st Street North, - Worthington, IA 52078 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. 2020-05-18 Jon Ramaekers jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Joyce Heims jheims@english-insurance.com self Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
315 2021-08-19 13:08 Anonymous (not verified) 173.26.33.84 CLINK FM, Inc. 110 N. Maryville Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-19 Kyana B Taillon kyanalily@gmail.com Oelwein Fayette IA Della Nehring Tim Nehring Signed (1) The corporation rejects the employers’ liability coverage. Jesse Y Goplen jesse@clink.fm Co-Founder/President Oelwein Fayette IA Della Nehring Tim Nehring Signed
314 2021-08-19 12:58 Anonymous (not verified) 173.26.33.84 CLINK FM, INC. 110 N. Maryville Street, Calmar, IA 52132 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-19 Jesse Y Goplen jessegoplen@gmail.com Oelwein Fayette IA Della Nehring Tim Nehring Signed (1) The corporation rejects the employers’ liability coverage. Kyana Taillon kyana@clink.fm Co-Founder/Vice-President Oelwein Fayette IA Della Nehring Tim Nehring Signed
163 2021-01-20 11:08 Anonymous (not verified) 173.233.46.58 Wasmer Post 241 Department of Iowa dba The American Legion 110 Plymouth St SW, Le Mars, IA 51031 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 Kim Wittmar mrkmjm@yahoo.com Le Mars Plymouth iA Muriel J. MIller Richard P. Miller Signed (1) The corporation rejects the employers’ liability coverage. Gary L. Konz claim_buster@yahoo.com Financial Officer Le Mars Plymouth IA Muriel J. Miller Richard P. Miller Signed
164 2021-01-20 11:11 Anonymous (not verified) 173.233.46.58 Wasmer Post 241, Department of Iowa dba The American Legion 110 Plymouth St SW, Le Mars, IA 51031 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 Andrew M. Schultze mrkmjm@yahoo.com Le Mars Plymouth IA Muriel J. Miller Richard P. Miller Signed (1) The corporation rejects the employers’ liability coverage. Gary L. Konz claim_buster@yahoo.com Financial Officer Le Mars Plymouth IA Muriel J. Miller Richard P. Miller Signed
165 2021-01-20 11:14 Anonymous (not verified) 173.233.46.58 Wasmer Post 241, Department of Iowa dba The American Legion 110 Plymouth St SW, Le Mars, IA 51031 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 Matthew Larson mrkmjm@yahoo.com Alton Sioux IA Muriel J. Miller Richard P. Miller Signed (1) The corporation rejects the employers’ liability coverage. Gary L. Konz claim_buster@yahoo.com Financial Officer Le Mars Plymouth IA Muriel J. Miller Richard P. Miller Signed
109 2020-08-24 14:41 Anonymous (not verified) 74.84.91.178 Rotten Love LLC 1101 Valentine Drive, Dubuque, IA 52003 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. 2020-08-14 Carolyn Schmid rottenlovellc@gmail.com Dubuque Dubuque Iowa Brenda Lewis Sue Miller Signed (1) The corporation rejects the employers’ liability coverage. Carolyn Schmid rottenlovellc@gmail.com partner Dubuque Dubuque IA Brenda Lewis Sue Miller Signed
929 2024-03-21 19:00 Anonymous (not verified) 94.188.205.167 Stewart and Belzer Construction 1103 n 8th 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. 2024-03-21 Logan belzer lbelzer1999@gmail.com Washington Washington Iowa Joseph Stewart Graham Hagge Signed (1) The corporation rejects the employers’ liability coverage. Logan belzer lbelzer1999@gmail.com Owner Washington Washington Iowa Joseph Stewart Graham Hagge Signed
530 2022-09-02 13:17 Anonymous (not verified) 173.20.146.6 Nicci Keck LLC 1107 Pheasant Valley St, Iowa City, IA 52246 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-02 Nicole Keck niccikeckllc@gmail.com Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed (1) The corporation rejects the employers’ liability coverage. Nicole Keck niccikeckllc@gmail.com Managing Member/Owner/President Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed
531 2022-09-02 13:19 Anonymous (not verified) 173.20.146.6 Nicci Keck LLC 1107 Pheasant Valley St, Iowa City, IA 52246 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-02 Benjamin Darbro darbrob@gmail.com Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed (1) The corporation rejects the employers’ liability coverage. Nicole Keck niccikeckllc@gmail.com Managing Member/Owner/President Iowa City Johnson Iowa Evangeline Kadera Denise Kandel Signed
116 2020-09-11 11:42 Anonymous (not verified) 69.57.22.68 Brush and Weed Control Specialists, Inc. 1108 230th Street - Algona, IA 50511 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-11 Ruth Jean Lindgren bwcontrol@netamumail.com Algona Kossuth Iowa James Black Katie Melvin Signed (1) The corporation rejects the employers’ liability coverage. Donald H Reffer bwcontrol@netamumail.com President and General Manager Algona Kossuth Iowa James Black Katie Melvin Signed
705 2023-07-06 14:24 Anonymous (not verified) 94.188.205.167 Portwood H3D Consulting 1109 295th Street, Oxford 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. 2023-07-06 Brian Portwood portwoodh3dconsulting@gmail.com Oxford Johnson Iowa Bob Herring Chelsey Atkinson Signed (1) The corporation rejects the employers’ liability coverage. Brian Portwood portwoodh3dconsulting@gmail.com owner Oxford Johnson Iowa Bob Herring Chelsey Atkinson Signed
335 2021-09-16 17:22 Anonymous (not verified) 64.142.5.50 Electrious Inc DBA Clean Tech 1110 Alhambra Ave Martinez CA 94533. I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-26 Robert Lemos robbie.lemos@clean.tech San Ramon Contra Costa County CA Teresa Leibnitz Greg Vermeulen Signed (1) The corporation rejects the employers’ liability coverage. Robbie Lemos robbie.lemos@clean.tech CEO San Ramon Contra Costa County CA Teresa Leibnitz Greg Vermeulen Signed
336 2021-09-16 18:53 Anonymous (not verified) 64.142.5.50 Electrious Inc DBA Clean Tech 1110 Alhambra Ave Martinez CA 94533. I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-26 Petr Brazdil petr.brazdil@clean.tech Trida Spojencu Brno Czechia in Europe Robbie Lemos Teresa Leibnitz Signed (1) The corporation rejects the employers’ liability coverage. Robbie Lemos robbie.lemos@clean.tech CEO SAN RAMON Contra Costa County CA Robbie Lemos Teresa Leibnitz Signed
593 2023-01-30 10:39 Anonymous (not verified) 69.18.9.193 ABC Fire Extinguisher Sales & Service, Inc. 112 Broadway Street Suite 2, West Burlington, IA 52655 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 Derek Stotlar contactabc@abc-fire.com Sperry Des Moines IA Kori Stotlar Jeff Elliott Signed (1) The corporation rejects the employers’ liability coverage. Kori Stotlar kstotlar@abc-fire.com President Sperry Des Moines IA Jeff Elliott Kim Eland Signed
552 2022-10-03 11:50 Anonymous (not verified) 173.18.48.197 Rancheros construction LLC 1121 Linn 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. 2022-09-25 Salvador Alvarez rancherosconstruction@outlook.com Waterloo Black hwak Iowa Jose Sergio Signed (1) The corporation rejects the employers’ liability coverage. Salvador Alvarez rancherosconstruction@outlook.com N/a Waterloo Black hawk Iowa Jose Sergio Signed
607 2023-02-20 21:53 Anonymous (not verified) 94.188.207.223 Rancheros construction LLC 1121 Linn Street Waterloo Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-09-15 Salvador Alvarez rancherosconstruction@outlook.com Waterloo Black hawk Iowa Adan Antonio Signed (1) The corporation rejects the employers’ liability coverage. Salvador Alvarez rancherosconstruction@outlook.com Owner Waterloo Black hawk Iowa Adan Antonio Signed
297 2021-07-30 11:05 Anonymous (not verified) 165.225.60.212 Love Tap Racing LLC 1122 Sunset Ave, Kelley, IA 50134 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. 2021-07-30 Timothy Love tiredemon@gmail.com Kelley Story IA Katie Frame Cody Jones Signed (1) The corporation rejects the employers’ liability coverage. Timothy Love tiredemon@gmail.com Owner Ames Story IA Katie Frame Cody Jones Signed
298 2021-07-30 11:05 Anonymous (not verified) 165.225.60.212 Love Tap Racing LLC 1122 Sunset Ave, Kelley, IA 50134 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. 2021-07-30 Laura Love tiredemon@gmail.com Kelley Story IA Katie Frame Cody Jones Signed (1) The corporation rejects the employers’ liability coverage. Laura Love tiredemon@gmail.com Owner Ames Story IA Katie Frame Cody Jones Signed
354 2021-11-04 16:26 Anonymous (not verified) 97.64.194.58 D&D Construction 1124 West Donald ST, Waterloo IA 50703 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. 2021-11-04 Darrel Caldwell dcaldwell1124@yahoo.com Waterloo Black Hawk County IA Scott Joseph Demuth Catrese Caldwell Signed (1) The corporation rejects the employers’ liability coverage. NA dcaldwell1124@yahoo.com NA NA NA NA NA NA Signed
519 2022-07-22 13:55 Anonymous (not verified) 162.253.44.28 Seeger Truck Trailer Repair, Inc. 1125 66th AVE 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. 2022-08-01 Eldora Seegers royalwsilverII@gmail.com Cedar Rapids Linn Iowa John Seegers Julie Jones Signed (1) The corporation rejects the employers’ liability coverage. Eldora Seergers royalwsilverII@gmail.com Officer Cedar Rapids Linn Iowa John Seegers Julie Jones Signed
895 2024-02-23 14:59 Anonymous (not verified) 94.188.205.169 Pas Construction LLC. 1125 Hubbard Ave Ne. Cedar rapids 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. 2024-02-23 Steven M. Helle helle4513@gmail.com Fairfax Linn Iowa Claudia Venable Matthew Himmel Signed (1) The corporation rejects the employers’ liability coverage. Steven Helle helle4513@gmail.com Owner Fairfax Linn Iowa Claudia Venable Matthew Himmel Signed
670 2023-05-18 12:21 Anonymous (not verified) 94.188.205.175 innovations General contractors 1134 20th ave East Moline IL 61244 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. 2022-05-18 Juan Carlos innovationsGENC@gmail.com East Moline Rock Island Illinois Jacinto Perez Lopez Pionaolo Davalos Signed (1) The corporation rejects the employers’ liability coverage. juan Carlos Soto Deanda InnovationsGENC@gmail.com owner East moline Rock Island illinois jacinto Perez Lopez Pianolo Davalos Signed
405 2022-02-14 10:36 Anonymous (not verified) 207.199.239.234 My Nest Greenhouse 1134-1600 St I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-14 Patti Bogler mynest@fmctc.com Harlan Iowa Iowa Hallie Carroll Katrina Shea Signed (1) The corporation rejects the employers’ liability coverage. Patti Bogler mynest@fmctc.com owner Harlan Iowa Iowa Hallie Lynn Carroll Katrina Mae Shea Signed
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
890 2024-02-19 12:07 Anonymous (not verified) 94.188.205.174 FJ Orisa Construction Inc 114 Austin Street SW I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-19 Jennifer LynnWeirup FJOrisaconstruction@yahoo.com Cedar Rapids Linn IA Karen Sedlacek Billie Jo Moore Signed (1) The corporation rejects the employers’ liability coverage. jennifer lynn weirup FJOrisaconstruction@yahoo.com self Cedar Rapids Iowa Iowa Karen Sedlacek Billie Jo Moore Signed
891 2024-02-19 12:09 Anonymous (not verified) 94.188.205.169 FJ Orisa Construction Inc 114 Austin Street SW I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-19 Felipe Aldana FJOrisaconstruction@yahoo.com Cedar Rapids Linn IA Karen Sedlacek Billie Jo Moore Signed (1) The corporation rejects the employers’ liability coverage. Felipe Aldana FJOrisaconstruction@yahoo.com officer Cedar Rapids Iowa Iowa Karen Sedlacek Billie Jo Moore Signed
779 2023-10-04 07:14 Anonymous (not verified) 94.188.207.225 CanD Homes, LLC 1147 Leitha Ter, Waverly, IA 50677 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 Alexander Eckard-Lewis alex.lewis@candhomes.com Waverly Bremer IA Connor Eustice Victor Sanders Signed (1) The corporation rejects the employers’ liability coverage. Alexander Eckard-Lewis alex.lewis@candhomes.com Vice President Waverly Bremer IA Connor Eustice Victor Sanders Signed
149 2020-12-31 14:59 Anonymous (not verified) 216.81.153.249 S&A Holdings LLC 115 N 2nd Street, Fort Dodge, IA 50501 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-21 Surinder Kumar NONE@GMAIL.COM Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Surinder Kumar NONE@GMAIL.COM Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
150 2020-12-31 15:00 Anonymous (not verified) 216.81.153.249 S&A Holdings LLC 115 N 2nd Street, Fort Dodge, IA 50501 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-21 Amritpal Singh amritaust1@gmail.com Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Amritpal Singh amritaust1@gmail.com Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
623 2023-03-08 13:48 Anonymous (not verified) 94.188.205.174 Jim & Laini's Trucking Inc 11591 Rupp Hollow 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. 2023-03-08 James Harry jltiowa@gmail.com DUBUQUE IA United States Christopher T Clarke Chris Clarke Signed (1) The corporation rejects the employers’ liability coverage. James Harry jltiowa@gmail.com owner DUBUQUE IA United States Christopher T Clarke Chris Clarke Signed
624 2023-03-08 13:50 Anonymous (not verified) 94.188.205.177 Jim & Laini's Trucking Inc 11591 Rupp Hollow 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. 2023-03-08 Elaine Harry jltiowa@gmail.com DUBUQUE Iowa United States Christopher T Clarke Chris Clarke Signed (1) The corporation rejects the employers’ liability coverage. James Harry jltiowa@gmail.com owner DUBUQUE IA United States Christopher T Clarke Chris Clarke Signed
795 2023-10-18 14:29 Anonymous (not verified) 94.188.205.169 Yarn Tree Designs Inc 117 Alexander Ave, Ames, IA 50010 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. 2023-10-18 Sarah Beth Johnson Beth@yarntree.com Ames Story Iowa Megan Chriswisser Erica Lenig Signed (1) The corporation rejects the employers’ liability coverage. Larry R Johnson larry@yarntree.com VP Ames Story Iowa Megan Chriswisser Erica Lenig Signed
796 2023-10-18 14:34 Anonymous (not verified) 94.188.205.177 Yarn Tree Designs Inc 117 Alexander Ave, Ames, IA 50010 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. 2023-10-18 Larry R Johnson larry@yarntree.com Ames Story Iowa Megan Chriswisser Erica Lenig Signed (1) The corporation rejects the employers’ liability coverage. Larry R Johnson larry@yarntree.com VP Ames Story Iowa Megan Chriswisser Erica Lenig Signed
671 2023-05-19 09:27 Anonymous (not verified) 94.188.205.176 Helle Drywall 118 ridge drive fairfax 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. 2023-05-19 Steven Helle helle4513@gmail.com Fairfax Linn Iowa Claudia Venable Matthew Himmel Signed (1) The corporation rejects the employers’ liability coverage. Steven Helle helle4513@gmail.com Owner/Self Fairfax Linn Iowa Claudia Venable Matthew Himmel Signed
350 2021-10-25 08:22 Anonymous (not verified) 208.95.64.3 Ron Sexton Construction Inc, 1184 Vine Ave, Riverside IA 52327 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-27 Ronald R Sexton ashmac@iowatelecom.net Riverside Washington IA Greg Martin Michele McMichael Signed (1) The corporation rejects the employers’ liability coverage. Ronald R Sexton ashmac@iowatelecom.net President Riverside Washington IA Greg Martin Michele McMichael Signed
351 2021-10-25 08:24 Anonymous (not verified) 208.95.64.3 Ron Sexton Construction Inc, 1184 Vine Ave, Riverside IA 52327 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-27 Theresa A Sexton ashmac@iowatelecom.net Riverside Washington IA Greg Martin Michele McMichael Signed (1) The corporation rejects the employers’ liability coverage. Theresa A Sexton ashmac@iowatelecom.net VP, Secretary, Treasurer Riverside Washington IA Greg Martin Michele McMichael Signed
748 2023-08-20 14:18 Anonymous (not verified) 94.188.205.177 NexLevelMoving 1186 capital dr sw I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2023-08-16 Ethan Daniel Sailer ethan.sailer@hscsi.net Cedar Rapids Linn County Iowa Denis Sailer Penny Sailer Signed (2) The corporation declines to reject the employers’ liability coverage. Tarin Erenberger tarin.nexlevelmoving@gmail.com Employee Cedar Rapids Linn County Iowa Taj Barrett Taj Barrett Signed
881 2024-02-05 11:08 Anonymous (not verified) 94.188.205.168 Nxt Level 1186 Capital Dr sw I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2024-02-05 Robert Sanders Sandersrob101300@gnail.com cedar rapids Linn iowa n/a n/a Signed (1) The corporation rejects the employers’ liability coverage. next level nextlevelmoving@gmail.com labor cedar rapids linn iowa n/a n/a Signed