300 |
2021-08-03 12:43 |
Anonymous (not verified) |
97.125.35.240 |
Every Solutions Drywall INC |
713 SE 7th St Des Moines, Iowa 50309 |
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. |
2021-08-03 |
Luis Hernandez |
everysolutiondrywainc@yahoo.com |
Des Moines |
Polk |
Iowa |
Kelly Denger |
Debra Stratton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Luis Hernandez |
everysoloutiondrywainc@yahoo.com |
Owner |
Des Moines |
Polk |
Ia |
Kelly Denger |
Debra Stratton |
Signed |
299 |
2021-08-02 10:55 |
Anonymous (not verified) |
97.125.35.240 |
L:ion BUilder Construction,, INC |
1705 E 32nd St Des Moines, Iowa 50317 |
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. |
2021-07-24 |
Carlos E Mondoza-Gutierrez |
gutierrezce1992@icloud.com |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Juana M.R. |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carlos E Mendoz-Gutierrez |
gutierrezce1992@icloud.com |
self |
Des Moines |
Polk |
Iowa |
Juan M. R. |
Debra Stratton |
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 |
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 |
296 |
2021-07-29 08:51 |
Anonymous (not verified) |
204.155.61.217 |
Blaine Management Inc |
660 NE Dellwood Dr Apt 17, Waukee, IA 5063 |
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. |
2021-07-29 |
Brent Ott |
brent@hailmayday.com |
Prior Lake |
Scott |
MN |
Ashley Kraft |
DocuSign |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brent Ott |
Brent@hailmayday.com |
Owner |
Prior Lake |
Scott |
MN |
Ashley Kraft |
Docusign |
Signed |
295 |
2021-07-27 15:13 |
Anonymous (not verified) |
75.162.64.21 |
Homars Concrete Inc. |
2439 se 19th st Des Moines IA 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-16 |
Omar Sacramento |
yasiel558@gmail.com |
Des Moines |
Polk |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Omar Sacramento |
yasiel558@gmail.com |
owner |
Des Moines |
polk |
iowa |
liliana sanchez |
yolanda mendoza |
Signed |
294 |
2021-07-27 14:10 |
Anonymous (not verified) |
173.19.179.111 |
MILFORD MECHANICAL INC |
1607 L AVE MILFORD, IA 51351 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-14 |
DUSITN BOER |
joel@walkerinsuranceia.com |
MILFORD |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
DUSTIN BOER |
joel@walkerinsuranceia.com |
PRESIDENT |
MILFORD |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
293 |
2021-07-26 12:39 |
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. |
2021-08-01 |
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 |
IA |
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 |
291 |
2021-07-26 12:31 |
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. |
2021-08-01 |
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 |
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 |
289 |
2021-07-22 17:47 |
Anonymous (not verified) |
172.58.83.5 |
Javier Construction INC |
2503 canyon st sw Cedar Rapids,iowa 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-22 |
Javier Aldana Fuentes |
Javierconstruction88@gmail.com |
Cedar Rapids |
Linn |
Iowa |
DaZsa Aldana |
Donya Fleetwood |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Javier Aldana Fuentes |
Javierconstruction88@gmail.com |
owner |
Cedar Rapids |
LInn |
Iowa |
DaZsa Aldana |
Donya Fleetwood |
Signed |
288 |
2021-07-22 16:17 |
Anonymous (not verified) |
104.166.243.230 |
Renewal By Anderson |
517 railroad ave. West Des Moines |
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. |
2021-07-22 |
Cameron Thede |
camthede22@gmail.com |
Windsor Heights |
Polk |
Iowa |
Mac Laven |
sdofkn |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Renewal By Andersen |
james@rbadesmoines.com |
Subcontractor |
West Des Moines |
Polk |
IA |
Mac Laven |
lsdfkn lsadnf |
Signed |
287 |
2021-07-19 11:58 |
Anonymous (not verified) |
207.199.222.199 |
STEPHEN MEMORIAL ANIMAL SHELTER INC |
1716 Pella 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. |
2021-06-26 |
Jeanie Bieri |
jeanie.bieri@musco.com |
Oskaloosa |
Mahaska |
Iowa |
Billy Blake |
Merri Chris Hawker |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeanie Bieri |
jeanie.bieri@musco.com |
Board President |
Oskaloosa |
Mahaska |
Iowa |
Billy Blake |
Merri Chris Hawker |
Signed |
286 |
2021-07-10 13:16 |
Anonymous (not verified) |
69.57.205.10 |
Marquis Aviation, Inc |
845 E. Redwood Cir. |
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. |
2021-07-10 |
Robert Wescott Cantrell |
rcr4@comcast.net |
Hanford |
Kings |
CA |
Shirley J. Loney |
Joel L. Meyer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert W. Cantrell |
rcr4@comcast.net |
Secretary |
Hanford |
Kings |
CA |
Shirley J. Loney |
Joel L. Meyer |
Signed |
285 |
2021-06-30 14:33 |
Anonymous (not verified) |
75.162.212.130 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave Apt 49 Clive, Iowa 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. |
2021-06-30 |
Luz Maria Morales Gutierrez |
lm3673719@gmail.com |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Superior Painting and Remodeling Corp |
lm3673719@gmail.com |
Owner |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
284 |
2021-06-30 14:27 |
Anonymous (not verified) |
75.162.212.130 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave Apt 49 Clive, Iowa 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. |
2021-06-30 |
Elmer Lopes Montufar |
lm3673719@gmail.com |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Superior Painting and Remodeling Corp |
lm3673719@gmail.com |
Owner |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
283 |
2021-06-30 14:24 |
Anonymous (not verified) |
75.162.212.130 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave Apt 49 Clive, Iowa 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. |
2021-06-30 |
Luz Maria Morales Gutierrez |
lm3673719@gmail.com |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Luz Maria Morales Gutierrez |
lm3673719@gmail.com |
Owner |
Des Moines |
United State |
Iowa |
Liliana Sanchez |
Yolanda Mendoza |
Signed |
282 |
2021-06-30 12:31 |
Anonymous (not verified) |
204.155.61.217 |
Stout Roofing Inc |
1200 Ash St, Dallas Center, IA 50063 |
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. |
2021-06-30 |
Jacob Stout |
jacobstout@hailmayday.com |
Dallas Center |
Dallas County |
IA |
Ashley Kraft |
Docusign |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jacob Stout |
jacobstout@hailmayday.com |
Owner |
Dallas center |
Dallas |
IA |
Ashley Kraft |
Docusign |
Signed |
281 |
2021-06-30 10:59 |
Anonymous (not verified) |
206.72.14.249 |
TCS Fabricating, Inc |
315 Hwy 22 Keswick, IA 50136 |
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. |
2021-06-30 |
Tom Sieren |
TCSFAB@NETINS.NET |
Keswick |
Keokuk |
Iowa |
Scott Grimm |
Amber Kephart |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tom Sieren |
TCSFAB@NETINS.NET |
Vice President |
Keswick |
IA |
United States |
Scott Grimm |
Amber Kephart |
Signed |
280 |
2021-06-29 16:51 |
Anonymous (not verified) |
50.83.167.103 |
King Kleen LLC |
421 S. 6th Street, Burlington, IA 52601 |
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. |
2021-06-29 |
Heidi King |
Kingbizsol@gmail.com |
Burlington |
Des Moines |
Iowa |
Ethan King |
Bob King |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Heidi King |
ethan@kingkleen.biz |
Owner |
Burlington |
Des Moines |
Iowa |
Ethan King |
Robert King |
Signed |
279 |
2021-06-23 10:41 |
Anonymous (not verified) |
184.80.177.137 |
AA Breeders |
P.O. Box 470 - Epworth, IA 52045 |
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. |
2021-06-22 |
Justin Curtis |
jheims@english-insurance.com |
Epworth |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
AA Breeders - Justin Curtis |
jheims@english-insurance.com |
self |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
278 |
2021-06-18 11:37 |
Anonymous (not verified) |
75.162.29.203 |
Digital Agronomy, LLC |
4270 199th St. Ames, IA 50014 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-06-17 |
Patrick T. Murphy |
ptmurphy82@gmail.com |
Ames |
Story |
Iowa |
David Cory |
Mary Cory |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Patrick T. Murphy |
ptmurphy82@gmail.com |
Owner |
Ames |
Story |
Iowa |
David Cory |
Mary Cory |
Signed |
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 |
276 |
2021-06-17 16:00 |
Anonymous (not verified) |
204.155.61.217 |
Gentle Bend Inc |
1075 120th Street Wellman, IA 52356 |
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 |
Greg Gent |
gentagincorporated@gmail.com |
Wellman |
Washington |
Iowa |
Jeff Spenner |
Shawn Powell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Greg Gent |
gentagincorporated@gmail.com |
Owner |
Wellman |
Washington |
Iowa |
Jeff Spenner |
Shawn Powell |
Signed |
275 |
2021-06-15 13:23 |
Anonymous (not verified) |
172.98.131.84 |
JAVIER CONSTRUCTION INC |
2503 Canyon St 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. |
2021-06-15 |
Javier Adana |
Javierconstruction88@gmail.com |
CEDAR RAPIDS |
LINN |
IOWA |
JASON SCHICK |
LADONNA SCHICK |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
JASON SCHICK |
JASONSCHICK@NEIGHBORINSURANCE.COM |
INSURANCE AGENT |
CEDAR RAPIDS |
LINN |
IOWA |
JASON SCHICK |
LADONNA SCHICK |
Signed |
274 |
2021-06-14 08:34 |
Anonymous (not verified) |
207.191.207.6 |
Total Health Rehabilitation PC |
4332 Pioneer Tr SE, Cedar Rapids, IA 52403 |
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. |
2021-06-14 |
Suzanne E. Cooper |
tcc@acterragroup.net |
Cedar Rapids |
Linn |
Iowa |
Tad C Cooper |
Hallie S Cooper |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Suzanne E. Cooper |
tcc@acterragroup.net |
President |
Cedar Rapids |
Linn |
Iowa |
Tad C Cooper |
Hallie S Cooper |
Signed |
273 |
2021-06-08 12:34 |
Anonymous (not verified) |
40.135.3.146 |
Gordinier Construction Inc |
9555 SE 6th Ave, Runnells IA 50237 |
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. |
2021-01-06 |
Dustin Gordinier |
gordinierconstruction@gmail.com |
Runnells |
Polk |
IA |
Robert Simmons |
Joe Meyers |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dustin Gordinier |
gordinierconstruction@gmail.com |
Self |
Runnells |
Polk |
IA |
Robert Simmons |
Joe Meyers |
Signed |
272 |
2021-06-08 12:32 |
Anonymous (not verified) |
40.135.3.146 |
Gordinier Construction Inc |
9555 SE 6th Ave, Runnells IA 50237 |
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. |
2021-01-06 |
Tim Gordinier |
gordinierconstruction@gmail.com |
Runnnells |
POLK |
IA |
Robert Simmons |
Joe Meyers |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tim Gordinier |
gordinierconstruction@gmail.com |
Self |
Runnells |
Polk |
IA |
Robert Simmons |
Joe Meyers |
Signed |
271 |
2021-06-01 15:39 |
Anonymous (not verified) |
206.72.14.249 |
TCS Fabricating, Inc |
315 Hwy 22 Keswick, IA 50136 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-21 |
Tom Sieren |
TCSFAB@NETINS.NET |
Keswick |
Keokuk |
Iowa |
Scott Grimm |
Amber Kephart |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tom Sieren |
TCSFAB@NETINS.NET |
Vice President |
Keswick |
Keokuk |
Iowa |
Scott Grimm |
Amber Kephart |
Signed |
270 |
2021-06-01 15:39 |
Anonymous (not verified) |
206.72.14.249 |
TCS Fabricating, Inc |
315 Hwy 22 Keswick, IA 50136 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-21 |
Lisa Sieren |
TCSFAB@NETINS.NET |
Keswick |
Keokuk |
Iowa |
Scott Grimm |
Amber Kephart |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Sieren |
TCSFAB@NETINS.NET |
President |
Keswick |
Keokuk |
Iowa |
Scott Grimm |
Amber Kephart |
Signed |
269 |
2021-05-25 20:25 |
Anonymous (not verified) |
174.71.12.114 |
The Town and Country Aqua Club of Council Bluffs |
15444 Cherry Tree Lane Council Bluffs, Iowa 51503 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-25 |
David Alan Bergman |
dbrgmn@gmail.com |
Council Bluffs |
Iowa |
United States |
Brett Ford |
Sean Dunphy |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Alan Bergman |
dbrgmn@gmail.com |
Board Vice President |
Council Bluffs |
Iowa |
United States |
Brett Ford |
Sean Dunphy |
Signed |
268 |
2021-05-25 10:03 |
Anonymous (not verified) |
174.198.97.100 |
Paradigm Construction, LLC |
960 Pelican Dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-25 |
Joshua Beougher |
jbooyah84@gmail.com |
Winterset |
Madison |
Iowa |
Ryan Shabino |
Jonathon Curtis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ryan Shabino |
ryan@prdgmconstruction.com |
Owner |
Polk City |
Polk |
Iowa |
Josh Beougher |
Jonathon Curtis |
Signed |
267 |
2021-05-24 11:25 |
Anonymous (not verified) |
70.168.33.178 |
Town and Country Aqua Club |
22687 James Dr, council bluffs, IA 51503 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-24 |
Cheri Smith |
3smithathome@cox.net |
Council Bluffs |
Pottawattamie |
IA |
Mark Smith |
Kirstyn Smith |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cheri Smith |
3smithathome@cox.net |
Secretary |
Council Bluffs |
Pottawattamie |
IA |
Mark Smith |
Kirstyn Smith |
Signed |
266 |
2021-05-22 13:38 |
Anonymous (not verified) |
75.162.162.238 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave. Apt. 49 Clive, Iowa 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. |
2021-05-22 |
Elmer Lopez Montufar |
lm3673719@gmial.com |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Superior Painting and Remodeling Corp |
lm3673719@gmial.com |
Owner |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
265 |
2021-05-22 13:33 |
Anonymous (not verified) |
75.162.162.238 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave. Apt. 49 Clive, Iowa 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. |
2021-05-22 |
Luz Maria Morales Gutierrez |
lm3673719@gmial.com |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Luz Maria Morales Gutierrez |
lm3673719@gmial.com |
Owner |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
264 |
2021-05-18 22:36 |
Anonymous (not verified) |
174.71.14.68 |
Town and country Aqua Club |
22687 James Dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-18 |
Hope LaShea Diercks |
townandcountrycb@gmail.com |
Council bluffs |
Pottawattamie |
Iowa |
John James Diercks |
Keenan James Diercks |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Hope LaShea Diercks |
townandcountrycb@gmail.com |
Treasurer |
Council bluffs |
Pottawattamie |
Iowa |
John James Diercks |
Keenan James Diercks |
Signed |
263 |
2021-05-06 15:18 |
Anonymous (not verified) |
174.243.113.232 |
Agronomic Solutions |
908 E Dubuque St Quasqueton IA 52326 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-06 |
Brandy Hodges |
mapping@agsolutionsinc.net |
Coon Rapids |
IA |
United States |
Jacki Sloss |
Don Sloss |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Friday Insurance |
doug.miller@fridayinsurance.net |
agent |
Osceola |
Clarke |
IA |
Jacki Sloss |
Don Sloss |
Signed |
262 |
2021-05-06 12:50 |
Anonymous (not verified) |
65.158.43.250 |
Maxter Roofing INC |
4112 E 14th St Des Moines, IA 50313 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-06 |
Gilberto Mata DBA Maxter Roofing INC |
oliviazavala120@yahoo.com |
Des Moines |
Polk |
IA |
Josh Bolton |
Olivia Zavala |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gilberto Mata DBA Maxter Roofing INC |
oliviazavala120@yahoo.com |
Owner |
Des Moines |
POLK |
IA |
Josh Bolton |
Olivia Zavala |
Signed |
261 |
2021-05-06 11:31 |
Anonymous (not verified) |
76.79.44.61 |
WOLTEMATH FARM INC |
3096 300TH AVE, Hamburg, IA 51640 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-06 |
Robert Allen Woltemath |
rwoltem@gmail.com |
Hamburg |
Fremont |
IOWA |
Lisa Reinier |
Sheryl Own |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandra Lynn Graybill |
sndygra@gmail.com |
Owner/ Officer |
Council Bluffs |
Pottawattamie |
IA |
Lisa Reinier |
Sheryl Owen |
Signed |
260 |
2021-05-06 11:12 |
Anonymous (not verified) |
76.79.44.61 |
Woltemath Farm Inc |
3096 300th 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. |
2021-05-06 |
Robert Allen Woltemath |
rwoltem@gmail.com |
Hamburg |
Fremont |
IA |
Lisa Reinier |
Sheryl Owen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandra Lynn Graybill |
sndygra@gmail.com |
Officer/Owner |
Council Bluffs |
Pottawattamie |
IA |
Lisa Reinier |
Sheryl Owen |
Signed |
259 |
2021-05-06 11:00 |
Anonymous (not verified) |
76.79.44.61 |
Woltemath Farm Inc |
3096 300th Ave, Hamburg, Ia 51640 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-06 |
Sandra Lynn Graybill |
sndygra@gmail.com |
Council Bluffs |
Pottawattamie |
United States |
Lisa Reinier |
Sheryl Owen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Woltemath |
rwoltem@gmail.com |
Officer/ Owner |
Hamburg |
Fremont |
IA |
Lisa Reinier |
Sheryl Owen |
Signed |
258 |
2021-05-06 10:57 |
Anonymous (not verified) |
76.79.44.61 |
Woltemath Farm Inc |
3096 300th Ave, Hamburg, Ia 51640 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-06 |
Robert Woltemath |
rwoltem@gmail.com |
HAMBURG |
IA |
United States |
Lisa Reinier |
Sheryl Owen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandra Lynn Graybill |
sndygra@gmail.com |
Officer/ Owner |
Council Bluffs |
Pottawattamie |
IA |
Lisa Reinier |
Sheryl Owen |
Signed |
257 |
2021-05-05 14:36 |
Anonymous (not verified) |
208.38.228.41 |
NSENSE inc |
415 Stanton Ave. Suite 205 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-05 |
David A. Laird |
dalaird@n-sense.us |
Ames |
Story |
IA |
Raina Powell |
Josh Powell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Laird |
dalaird@n-sense.us |
President |
Ames |
Story |
IA |
Besta Pruski |
Marek Pruski |
Signed |
256 |
2021-05-05 08:04 |
Anonymous (not verified) |
206.127.178.33 |
NSense, Inc. |
415 Stanton Ave Suite 205, Ames, IA 50014 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-05 |
Stephen R Ringlee |
sringlee@n-sense.us |
Ames |
Story |
Iowa |
Constance J. Ringlee |
Robert Anders |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Stephen R Ringlee |
sringlee@n-sense.us |
Director |
Ames |
Story |
Iowa |
Constance J Ringlee |
Robert Anders |
Signed |
255 |
2021-05-04 21:04 |
Anonymous (not verified) |
208.38.228.16 |
NSENSE Incorporated |
415 Stanton Ave, Suite 205, Ames, IA 50014 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-04 |
Natalia Rogovska |
nrogovska@n-sense.us |
Ames |
Story |
Iowa |
Petro Kyveryga |
Halyna Mudryk |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Natalia Rogovska |
nrogovska@n-sense.us |
Vice-President |
Ames |
Story |
Iowa |
Petro Kyveryga |
Halyna Mudryk |
Signed |
254 |
2021-05-04 17:25 |
Anonymous (not verified) |
208.38.228.16 |
NSENSE Incorporater |
415 Stanton Ave, Suite 205, Ames, IA 50014 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-04 |
Natalia Rogovska |
nrogovska@n-sense.us |
Ames |
Story |
Iowa |
Halyna Mudryk |
Petro Kyveryga |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Natalia Rogovska |
nrogovska@n-sense.us |
Vice-President |
Ames |
Story |
Iowa |
Halyna Mudryk |
Petro Kyveryga |
Signed |
253 |
2021-05-04 16:17 |
Anonymous (not verified) |
207.32.14.70 |
Experts Roofing LLC |
8655 81st St S, Cottage Grove MN 55016 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-04 |
Victor Oropeza |
vikrosales@hotmail.com |
Cottage Grove |
Washington |
MN |
Emily Danner |
Michael Karels |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Victor Oropeza |
vikrosales@hotmail.com |
Owner |
Cottage Grove |
Washington |
MN |
Emily Danner |
Michael Karels |
Signed |
252 |
2021-05-04 13:47 |
Anonymous (not verified) |
159.242.43.24 |
J. Fox Distributing, Inc |
3801 Pierce Street, Sioux City, IA 51104 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-04 |
Joseph Fox |
huskerjoe12@gmail.com |
Sioux City |
Woodbury |
IA |
Jenny McIntyre |
Alex Meier |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Fox |
huskerjoe12@gmail.com |
President |
Sioux City |
Woodbury |
IA |
Jenny McIntyre |
Alex Meier |
Signed |
251 |
2021-05-04 13:39 |
Anonymous (not verified) |
159.242.43.24 |
Parrott Distributing, Inc |
1429 16th Ave SE, Lemars, 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. |
2021-05-04 |
Jason Parrott |
jlparrott@premieronline.net |
Lemars |
Plymouth |
IA |
Jenny McIntyre |
Josh Olson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jason Parrott |
jlparrott@premieronline.net |
President |
Lemars |
Plymouth |
IA |
Jenny McIntyre |
Josh Olson |
Signed |