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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:
66 2020-04-20 13:41 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Tresa Hussong jennifer@walkerinsuranceia.com Arnolds Park Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Tresa Hussong jennifer@walkerinsuranceia.com Board Member Arnolds Park Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
67 2020-04-20 13:46 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 John Franken jennifer@walkerinsuranceia.com Spirit Lake Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. John Franken jennifer@walkerinsuranceia.com Vice President Spirit Lake Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
68 2020-04-20 13:50 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Jill Harms jennifer@walkerinsuranceia.com Milford Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Jill Harms jennifer@walkerinsuranceia.com President Milford Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
226 2021-04-01 11:52 Anonymous (not verified) 97.125.87.4 JK Holdings 1300 NW 100TH ST. Suite 3000 Clive, IA 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Joey Boyens ekindesmoines@gmail.com Clive Polk Iowa Jenae Halstead Cam Naylor Signed (1) The corporation rejects the employers’ liability coverage. Jenae Halstead ekindesmoines@gmail.com Manager Clive Polk Iowa Joey Boyens Cam Naylor Signed
54 2020-04-03 19:30 Anonymous (not verified) 173.25.134.162 Luke Laxton 1502 guthrie ave I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-03 Luke Laxton kyekingstonl@gmail.com Des Moines Iowa United States Omer Okic Nicholas weber Signed (1) The corporation rejects the employers’ liability coverage. Luke Laxton kyekingstonl@gmail.com Owner Des Moines Iowa United States Omer Okic Nicholas weber Signed
55 2020-04-06 16:25 Anonymous (not verified) 74.221.44.37 Steele Land & Livestock, Inc 1040 190th St, Anita, IA 50020 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-06 Doug Steele dsteele@midlands.net Anita Adair Iowa Sheryl Leonard Cheryl Ellis Signed (1) The corporation rejects the employers’ liability coverage. Doug Steele dsteele@midlands.net President Anita Adair Iowa Sheryl Leonard Cheryl Ellis Signed
56 2020-04-10 11:12 Anonymous (not verified) 136.34.78.83 KALONA SALES BARN, INC. 121 9TH ST; KALONA, IA 52247 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-06 LAVAUGHN MULLET LMULLET@KALONASALESBARN.COM KALONA WASHINGTON IOWA ALANA MULLET ROCHELLE MULLET Signed (1) The corporation rejects the employers’ liability coverage. LAVAUGHN MULLET LMULLET@KALONASALESBARN.COM OWNER KALONA WASHINGTON IOWA ALANA MULLET ROCHELLE MULLET Signed
57 2020-04-10 11:14 Anonymous (not verified) 136.34.78.83 KALONA SALES BARN, INC. 191 9TH STREET; KALONA, IA 52247 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-07 DEVIN MULLET LMULLET@KALONASALESBARN.COM KALONA WASHINGTON IOWA ALANA MULLET ROCHELLE MULLET Signed (1) The corporation rejects the employers’ liability coverage. DEVIN MULLET LMULLET@KALONASALESBARN.COM OWNER KALONA WASHINGTON IOWA ALANA MULLET ROCHELLE MULLET Signed
59 2020-04-14 12:54 Anonymous (not verified) 65.126.161.162 Elite Carpentry 1515 21st Street 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. 2020-04-10 Jeffrey D. Leech elitecarpentryqc@gmail.com Bettendorf Scott Iowa Sarah Robertson Beth Welzenbach Signed (2) The corporation declines to reject the employers’ liability coverage. Jeffrey D. Leech elitecarpentryqc@gmail.com President Bettendorf Scott Iowa Sarah Robertson Beth Welzenbach Signed
58 2020-04-14 08:32 Anonymous (not verified) 174.217.17.57 Society of St Vincent de Paul, District Counsel Waterloo Iowa 320 Broadway St PO Box 2727 Waterloo IA 50704 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-14 Rodney Crowe crorod@aol.com Waterloo Blackhawk Iowa George W Karnivk Glynis R Worthington Signed (1) The corporation rejects the employers’ liability coverage. Joseph D Sobczyk joczyk@aol.com Corporate Treasurer Cdear Falls Blackhawk Iowa George W Karnick Glynis R Worthington Signed
69 2020-04-21 10:18 Anonymous (not verified) 65.126.161.162 Mike Foster DBA Mike's Home Improvement 2377 W 49th Street Davenport, IA 52806 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-21 Michael A Foster Jr. None@none.com Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed (1) The corporation rejects the employers’ liability coverage. Michael A Foster Jr. None@none.com Owner Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed
70 2020-04-21 10:29 Anonymous (not verified) 173.24.181.211 Mr. Drain Man LLC 607 36th Street, Spirit Lake IA 51360 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-21 Jan Coon jennifer@walkerinsuranceia.com Spirit Lake Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Mr Drain Man LLC jennifer@walkerinsuranceia.com Member Spirit Lake Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
76 2020-05-04 10:24 Anonymous (not verified) 173.191.207.202 Tim Fitzgerald Mechanical Services, Inc. 724 1st Ave W - 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. 2020-04-24 Tim Fitzgerald 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-English Insurance Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
73 2020-04-28 22:27 Anonymous (not verified) 72.25.27.81 Clanton Creek Land Improvement 3094 Pheasant Run Trail Peru, IA 50222 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-28 Travis James Tuttle t.tuttle1982@gmail.com Peru Madison Iowa Sabrina Elaine Tuttle Spencer Gregory Minnich Signed (1) The corporation rejects the employers’ liability coverage. Travis James tuttle t.tuttle1982@gmail.com President Peru Madison Iowa Sabrina Elaine Tuttle Spencer Gregory Minnich Signed
74 2020-04-29 05:29 Anonymous (not verified) 198.14.245.254 Clanton Creek Land Improvement 2094 Pheasant Run Trail Peru Iowa 50222 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-28 Spencer Minnich sminnich85@hotmail.com Peru Madison Iowa Sarah Minnich Travis Tuttle Signed (1) The corporation rejects the employers’ liability coverage. Spencer Minnich sminnich85@hotmail.com Vice President Peru Madison Iowa Sarah Minnich Travis Tuttle Signed
75 2020-04-29 11:07 Anonymous (not verified) 107.77.206.22 ACR Construction, Inc 7330 NW 21 St. Ankeny, IA 50023 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-29 Andre Sean Drost andre.drost@acr-construction-inc.com Ankeny Polk IA Heidi Smith Jeff Smith Signed (1) The corporation rejects the employers’ liability coverage. Candace Drost acrdrost@hotmail.com President Ankeny Polk IA Heidi Smith Jeff Smith Signed
85 2020-06-03 17:53 Anonymous (not verified) 75.162.69.231 Blackford Foundations Inc 501 SW Franklin Dr, Ankeny, IA 50023 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-05-01 Brenda Marie Blackford brendab@blackfordfoundations.com Ankeny Polk Iowa Saree Luce Ricky Eatwell Signed (1) The corporation rejects the employers’ liability coverage. Brenda Marie Blackford brendab@blackfordfoundations.com President Ankeny Polk Iowa Saree Luce Ricky Eatwell Signed
86 2020-06-03 17:56 Anonymous (not verified) 75.162.69.231 Blackford Foundations Inc 501 SW Franklin Dr, Ankeny, IA 50023 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-05-01 Denny Lee Blackford blackfordfoundations@gmail.com Ankeny Polk Iowa Saree Luce Ricky Eatwell Signed (1) The corporation rejects the employers’ liability coverage. Denny Lee Blackford blackfordfoundations@gmail.com Secretary Ankeny Polk Iowa Saree Luce Ricky Eatwell Signed
97 2020-07-09 10:07 Anonymous (not verified) 173.215.13.54 LOS DOS MEXICAN RESTAURANT DBA CASA DE ORO 1211 2ND ST, PERRY IOWA 50220 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. 2020-05-01 MARIO LEPE DAVID.FINNESETH@FBFS.COM PERRY DALLAS IOWA ROBERTA L GILSON SANDRA S WHEELER Signed (1) The corporation rejects the employers’ liability coverage. MARIO LEPE DAVID.FINNESETH@FBFS.COM VICE PRESIDENT PERRY DALLAS IOWA ROBERTA L GILSON SANDRA S WHEELER Signed
77 2020-05-05 16:47 Anonymous (not verified) 173.21.16.121 Kevan Oliver Trim Carpentry, Inc. 2900 Scott Park Road, Eldridge, IA 52748 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. 2020-05-05 Kevan Oliver kkoliverinc@gmail.com Eldridge Scott Iowa Franco Muñoz Rolando Muñoz Signed (2) The corporation declines to reject the employers’ liability coverage. Kevan Oliver kkoliverinc@gmail.com President Eldridge Scott Iowa Franco Muñoz Rolando Muñoz Signed
78 2020-05-05 16:49 Anonymous (not verified) 173.21.16.121 Kevan Oliver Trim Carpentry, Inc. 2900 Scott Park Road, Eldridge, IA 52748 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. 2020-05-05 Scarlett Oliver scarlettioliver@gmail.com Eldridge Scott Iowa Franco Muñoz Rolando Muñoz Signed (2) The corporation declines to reject the employers’ liability coverage. Kevan Oliver kkoliverinc@gmail.com President Eldridge Scott Iowa Franco Muñoz Rolando Muñoz Signed
79 2020-05-06 08:14 Anonymous (not verified) 97.125.243.140 pro plumbing and heating llc 903 nw 37th ct ankeny iowa 50023 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-05-06 lee d kearney ankenypro@gmail.com ankeny polk iowa sheila m kearney keegan l kearney Signed (1) The corporation rejects the employers’ liability coverage. lee d kearney ankenypro@gmail.com owner ankeny IA United States sheila m kearney keegan l kearney Signed
80 2020-05-11 12:29 Anonymous (not verified) 173.191.207.202 J&D Furniture-Land Corp 144 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. 2020-05-07 Scott Hittenmiller dparsons@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 agent-English Insurance Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
81 2020-05-11 16:10 Anonymous (not verified) 97.125.253.184 Rundle Creations L.L.C. 5816 Urbandale Avenue, Des Moines, IA 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. 2020-05-11 Mark Lavern Rundle II rundlecreations@gmail.com Des Moines Polk Iowa Luis Alex Jimenez Jennifer Lea Griffith Signed (1) The corporation rejects the employers’ liability coverage. Erika Anne Rundle rundlecreations@gmail.com Owner Des Moines Polk Iowa Luis Alex Jimenez Jennifer Lea Griffith 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
83 2020-05-20 12:34 Anonymous (not verified) 108.171.131.188 North Iowa Custom Seamless Guttering, Inc PO Box 512, 1300 2nd Ave S, Clear Lake, Iowa 50428 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-05-20 Keith E Main keithmaincsg@hotmail.com Clear Lake Cerro Gordo Iowa Lloyd L Heinselman Diane K Harrington Signed (1) The corporation rejects the employers’ liability coverage. Keith E Main keithmaincsg@hotmail.com President Clear Lake Cerro Gordo Iowa Lloyd L Heinselman Diane K Harrington Signed
84 2020-06-01 16:31 Anonymous (not verified) 173.29.126.110 TruthPoint Media LLC 1945 Andrews Drive, Pleasant Hill, IA 50327 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. 2020-06-01 Robert Lee Moore robb@truthpointmedia.com Pleasant Hill Polk Iowa Self, Sole Proprietor and LLC Member, TruthPoint Media LLC Self, Sole Proprietor and LLC Member, TruthPoint Media LLC Signed (1) The corporation rejects the employers’ liability coverage. Robert L Moore robb@truthpointmedia.com Self Pleasant Hill Polk Iowa Self, Sole Proprietor and LLC Member, TruthPoint Media LLC Self, Sole Proprietor and LLC Member, TruthPoint Media LLC Signed
87 2020-06-09 14:49 Anonymous (not verified) 185.169.109.170 Sweeney Builders Inc 511 8th Ave NW I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-06-09 Michael Lee Sweeney mike@sweeneybuilders.com Waukon Allamakee Iowa Shawna Sweeney Jean Gavin Signed (1) The corporation rejects the employers’ liability coverage. Shawna Sweeney shawna@sweeneybuilders.com Vice President Waukon Allamakee IA Mike Sweeney Jean Gavin Signed
88 2020-06-10 11:36 Anonymous (not verified) 173.28.7.32 DMG INSTALLATIONS INC 5534 NE 17TH ST #4 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. 2020-06-10 DAVID PAUL DUNLAP HAYDAVE@AOL.COM DES MOINES POLK IOWA JASON DAVID MUSSO CLIFFORD LEE BAKER Signed (1) The corporation rejects the employers’ liability coverage. CLIFF BAKER CLBAKER@MEDIACOMBB.NET PRESIDENT ALTOONA POLK IOWA JASON DAVID MUSSO DAVID PAUL DUNLAP Signed
89 2020-06-10 11:42 Anonymous (not verified) 173.28.7.32 DMG INSTALLATIONS INC 5534 NE 17TH ST #4 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. 2020-06-10 JASON DAVID MUSSO JMUSSO74@GMAIL.COM BONDURANT POLK IOWA DAVID PAUL DUNLAP CLIFFORD LEE BAKER Signed (1) The corporation rejects the employers’ liability coverage. CLIFFORD LEE BAKER CLBAKER@MEDIACOMBB.NET PRESIDENT ALTOONA POLK IOWA JASON DAVID MUSSO DAVID PAUL DUNLAP Signed
90 2020-06-10 11:46 Anonymous (not verified) 173.28.7.32 DMG INSTALLATIONS INC 5534 NE 17TH ST #4 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. 2020-06-10 CLIFFORD LEE BAKER CLBAKER@MEDIACOMBB.NET ALTOONA POLK IOWA DAVID PAUL DUNLAP JASON DAVID MUSSO Signed (1) The corporation rejects the employers’ liability coverage. CLIFFORD LEE BAKER CLBAKER@MEDIACOMBB.NET PRESIDENT ALTOONA POLK IOWA JASON DAVID MUSSO DAVID PAUL DUNLAP 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
101 2020-07-16 13:07 Anonymous (not verified) 173.28.28.57 Weikert Properties, LLC 34520 175th Street, Cedar Falls IA 5061 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. 2020-06-23 Caleb Weikert cmins_re@mchsi.com Cedar Falls Grundy Iowa Chad Campbell Roxanne Kolder Signed (1) The corporation rejects the employers’ liability coverage. Caleb Weikert cmins_re@mchsi.com Self Cedar Falls Grundy Iowa Chad Campbell Roxanne Kolder Signed
94 2020-07-02 08:19 Anonymous (not verified) 174.217.21.87 James Subcontracting 5212 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. 2020-07-02 James Lee Wardell jlw21479@gmail.com Des Moines IA United States Tammy Wardell Bobby Hoch Signed (1) The corporation rejects the employers’ liability coverage. James Subcontracting jlw21479@gmail.com Owner Des Moines IA United States Tammy Wardell Bobby Hoch Signed
95 2020-07-02 10:30 Anonymous (not verified) 206.125.132.254 Dave Prochaska Construction 5848 Hopeview Ct 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. 2020-07-02 Dave Prochaska kschepers@nelsonbrothersagency.com Bettendorf Scott IA Kaitlin Schepers Lori Fisher Signed (1) The corporation rejects the employers’ liability coverage. Dave Prochaska kschepers@nelsonbrothersagency.com Owner Bettendorf Scott IA Kaitlin Schepers Lori Fisher Signed
96 2020-07-03 16:51 Anonymous (not verified) 208.90.8.234 Humboldt Co. Ag Society 311 6th Ave. N Humboldt 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. 2020-07-03 Jeffrey D. Halverson roadgear54@yahoo.com Hardy Humboldt Iowa Marva Anderson Paul Davis Signed (1) The corporation rejects the employers’ liability coverage. Jeffrey Halverson roadgear54@yahoo.com Vice President Hardy Humboldt Iowa Marva Anderson Paul Davis Signed
98 2020-07-11 16:34 Anonymous (not verified) 50.83.184.81 Paradigm Construction LLC 1847 nw 90th st Clive, IA 50325 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. 2020-07-06 Jonathon Richard Curtis joncurtis15@gmail.com Des Moines Polk IA Yolanda Curtis Susan Brooker Signed (2) The corporation declines to reject the employers’ liability coverage. Ryan Shabino ryan@prdgmconstruction.com Contractor Clive Polk IA Yolanda Curtis Susan Brooker Signed
99 2020-07-12 13:29 Anonymous (not verified) 207.32.58.202 Subject Enterprise, Inc. 165 210th St Wesley, IA 50483 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-07-12 Coda Subject subjectenterprise@gmail.com Britt Hancock IA Keri Byom Steve Schlichting Signed (1) The corporation rejects the employers’ liability coverage. Coda Subject subjectenterprise@gmail.com Owner Britt Hancock IA Keri Byom Steve Schlichting Signed
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
100 2020-07-14 19:08 Anonymous (not verified) 208.90.8.234 Humboldt County Agricultural 311 N 6th Ave, P.O. Box 391, Humboldt, IA 50548 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. 2020-07-18 Jeff Haselhuhn gjhaselhuhn@gmail.com Humboldt Humboldt IA Marva Anderson Jeff Halverson Signed (1) The corporation rejects the employers’ liability coverage. Marva Anderson info@humboldtcountyfair.com Business Manager Humboldt 81 81 Marva Anderson Jeff Halverson Signed
102 2020-07-19 14:42 Anonymous (not verified) 208.90.8.234 Humboldt County Agricultural Society 311 N 6th Ave P.O. Box 391, Humboldt, IA 50548 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. 2020-07-19 Paul Davis dfs72@yahoo.com Humboldt Humboldt IA Marva Anderson Paul Davis Signed (1) The corporation rejects the employers’ liability coverage. Humboldt County Agricultural Society info@humboldtcountyfair.com Business Manager Humboldt 81 IA Marva Anderson Jeff Halverson Signed
103 2020-07-23 09:23 Anonymous (not verified) 184.80.177.137 Jacob Reiff 15738 N Cascade Rd - Peosta, IA 52068 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. 2020-07-23 Jacob Reiff jheims@engish-insurance.com Peosta, Dubuque Iowa Joyce Heims Derrick Parsons Signed (2) The corporation declines to reject the employers’ liability coverage. Joyce Heims jheims@english-insurance.com owner Peosta Dubuque Iowa Joyce Heims Derrick Parsons Signed
104 2020-07-24 10:07 Anonymous (not verified) 173.24.248.4 Dirty 30 Trucking & Excavating 3018 Lawnview Drive I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-07-24 Kirkland Davidson dirty30iowa@gmail.com Mt. Ayr Ringgold Iowa Alexandra Peace Rahim Martin Signed (1) The corporation rejects the employers’ liability coverage. Kirkland Davidson dirty30iowa@gmail.com President Des Moines Polk Iowa Alexandra Peace Rahim Martin Signed
105 2020-07-24 18:21 Anonymous (not verified) 74.115.101.23 Humboldt County Agricultural Society 311 N 6th Ave P.O. Box 391, Humboldt, IA 50548 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. 2020-07-24 Kevin Cordray kwcordray@gmail.com Humboldt Humboldt IA Marva Anderson Jeff Halverson Signed (1) The corporation rejects the employers’ liability coverage. Humboldt County Agricultural Society info@humboldtcountyfair.com Business Manager Humboldt Humboldt IA Marva Anderson Jeff Halverson 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
290 2021-07-26 12:29 Anonymous (not verified) 208.95.1.97 Chyma's Welding, Inc. 206 2nd Ave, Toledo IA 52342 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. 2020-08-01 Chad Chyma Chymamenwelding@windstream.net Toledo Tama IA Matt Zmolek Michaela Chyma Signed (1) The corporation rejects the employers’ liability coverage. Chad Chymamenwelding@windstream.net Director Toledo IA United States Matt Zmolek Michaela Chyma Signed
292 2021-07-26 12:38 Anonymous (not verified) 208.95.1.97 Chyma's Machine and Welding Shop, Inc. 206 2nd Ave, Toledo IA 52342 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. 2020-08-01 Chad Chyma Chymamenwelding@windstream.net Toledo Tama Iowa Matt Zmolek Michaela Chyma Signed (1) The corporation rejects the employers’ liability coverage. Chad Chyma Chymamenwelding@windstream.net Director Toledo Tama Iowa Matt Zmolek Michaela Chyma 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
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