200 |
2021-03-03 17:33 |
Anonymous (not verified) |
172.58.84.30 |
Amee Ann Pepperson |
1536 1/2 W Locust |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-03 |
Amee Ann Pepperson |
amee0818@yahoo.com |
Davenport |
Scott |
Iowa |
Philip Gerald Hoxsey |
Michael Wayne Underdahl |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Amee A Pepperson |
amee0818@yahoo.com |
Self |
Davenport |
Scott |
Iowa |
Michael Wayne Underdahl |
Philip Gerald Hoxsey |
Signed |
199 |
2021-03-03 17:32 |
Anonymous (not verified) |
172.58.86.222 |
Mike Underdahl |
1536 W Locust 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. |
2021-03-03 |
Mike Underdahl |
mwunderdahl1974@gmail.com |
Davenport |
Scott |
Iowa |
Phillip Gerald Hoxsey |
Amee Ann Pepperson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Wayne Underdahl |
mwunderdahl1974@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Phillip Gerald Hoxsey |
Amme Ann Pepperson |
Signed |
198 |
2021-03-03 17:14 |
Anonymous (not verified) |
173.29.156.163 |
Jdw |
329 E. 11th st davenport iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-03 |
James holzer |
slickninja00@gmail.com |
Davenport |
Scott |
Iowa |
Alyssa holzer |
Kory munn |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
James holzer |
slickninja00@gmail.com |
Myself |
Davenport |
Scott |
Iowa |
Alyssa holzer |
Kory munn |
Signed |
197 |
2021-03-03 11:16 |
Anonymous (not verified) |
173.31.147.225 |
TLI INVESTMENTS INC |
1712 368TH AVE ESTHERVILLE, IA 51334 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-15 |
TRACE IVERSON |
JOEL@WALKERINSURANCE.COM |
ESTHERVILLE |
EMMET |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
TRACE IVERSON |
TBYRDLES@YAHOO.COM |
VICE PRESIDENT |
ESTHERVILLE |
EMMET |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
196 |
2021-03-03 11:11 |
Anonymous (not verified) |
173.31.147.225 |
TLI INVESTMENTS INC |
1712 368TH AVE ESTHERVILLE, IA 51334 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-15 |
LESLI IVERSON |
TBYRDLES@YAHOO.COM |
ESTHERVILLE |
EMMET |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LESLI IVERSON |
TBYRDLES@YAHOO.COM |
PRESIDENT |
ESTHERVILLE |
EMMET |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
195 |
2021-03-02 16:29 |
Anonymous (not verified) |
173.29.156.163 |
Certified drywall |
329 e.11th st Davenport, Iowa 52803 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-02 |
Thomas wells |
mikeparry783@gmail.com |
Davenport |
Scott |
Iowa |
Chyna rose pena |
Natalie parry |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Thomas wells |
mikeparry783@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Chyna rose pena |
Natalie parry |
Signed |
194 |
2021-03-02 11:42 |
Anonymous (not verified) |
50.83.72.164 |
D’s Drywall |
1217 n Blanchard 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. |
(2) I decline to reject the employer’s liability coverage. |
2021-03-02 |
Donivan hoxsey |
hdonivan@gmail.com |
Davenport |
Scott |
Iowa |
Phillip hoxsey |
Connor ruge |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Donivan hoxsey |
hdonivan@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Phillip hoxsey |
Connor ruge |
Signed |
193 |
2021-03-02 11:32 |
Anonymous (not verified) |
50.83.72.164 |
4 corners drywall |
532 w 15 st, Davenport, iowa 52803 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-03-02 |
Phillip hoxsey |
Phillhoxsey81@gmail.com |
Davenport |
Scott |
Iowa |
Donivan hoxsey |
Connor ruge |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Phillip hoxsey |
Phillhoxsey81@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Donivan hoxsey |
Connor ruge |
Signed |
192 |
2021-02-25 11:10 |
Anonymous (not verified) |
173.27.130.150 |
Southside Boat Club |
Post Office Box 674, Keokuk, Iowa 52632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-01 |
Jeri Asbridge |
kerryasbridge1@mediacombb.net |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeri Asbridge |
Kerryasbridge1@mediacombb.net |
Treasurer |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
191 |
2021-02-25 11:07 |
Anonymous (not verified) |
173.27.130.150 |
Southside Boat Club |
Post Office Box 674, Keokuk, Iowa 52632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-01 |
Karen Colleen Rude |
kacee61@hotmail.com |
Keokuk |
Lee |
Iowa |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeri Asbridge |
Kerryasbridge1@mediacombb.net |
Treasurer |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
190 |
2021-02-25 10:57 |
Anonymous (not verified) |
173.27.130.150 |
Southside Boat Club |
Post Office Box 674, Keokuk, Iowa 52632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-01 |
Kathryn L. Farris |
southsideboatclub@gmail.com |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeri Denise Asbridge |
Kerryasbridge1@mediacombb.net |
Treasurer |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
189 |
2021-02-25 10:56 |
Anonymous (not verified) |
173.27.130.150 |
Southside Boat Club |
Post Office Box 674, Keokuk, Iowa 52632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-01 |
Kathryn L. Farris |
southsideboatclub@gmail.com |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeri Denise Asbridge |
Kerryasbridge1@mediacombb.net |
Treasurer |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
188 |
2021-02-25 10:46 |
Anonymous (not verified) |
173.24.190.134 |
Shamrock Recycling, Inc. |
PO Box 304, Emmetsburg, IA 50536 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-26 |
Michael H. Flannegan |
shamrock@ncn.net |
Emmetsburg |
Palo Alto |
Iowa |
Cindy Flannegan |
Laura Sidles |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael H Flannegan |
shamrock@ncn.net |
President |
Emmetsburg |
Palo Alto |
Iowa |
Cindy Flannegan |
Laura Sidles |
Signed |
187 |
2021-02-25 10:44 |
Anonymous (not verified) |
173.27.130.150 |
Southside Boat Club |
Post Office Box 674, Keokuk, Iowa 52632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-01 |
Michael Oney Mahoney |
southsideboatclub@gmail.com |
Keokuk |
Lee |
Iowa |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeri Denise Asbridge |
Kerryasbridge1@mediacombb.net |
Treasurer |
Hamilton |
Hancock |
Illinois |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
186 |
2021-02-24 14:35 |
Anonymous (not verified) |
216.51.194.37 |
Estherville Aviation, Inc. |
1672 425th Ave, Estherville, IA 51334 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-24 |
Paul Abrams Slaughter |
estavtn@yourstarnet.net |
Estherville |
Emmet |
Iowa |
Jordan Lampman |
Dwayne Hoss |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Abrams Slaughter |
estavtn@yourstarnet.net |
President |
Estherville |
Emmet |
Iowa |
Jordan Lampman |
Dwayne Hoss |
Signed |
185 |
2021-02-23 15:16 |
Anonymous (not verified) |
173.29.151.168 |
TONY V'S PAINTING |
2316 CRESCENT AVE DAVENPORT, IA 52804 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-23 |
ANTHONY VANCE |
ANTHONYJV1977@GMAIL.COM |
DAVENPORT |
SCOTT |
IA |
TONY BURKHART |
RICHARD MILLER-VANCE |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ANTHONY VANCE |
ANTHONYJV1977@GMAIL.COM |
OWNER |
DAVENPORT |
SCOTT |
IA |
TONY BURKHART |
RICHARD MILLER-VANCE |
Signed |
184 |
2021-02-20 15:18 |
Anonymous (not verified) |
75.162.213.162 |
MJM, INC. |
32345 - 200TH 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. |
2021-02-20 |
MICHAEL CONNOLLY |
MJMINC2000@AOL.COM |
Dallas Center |
Iowa |
United States |
Stephen L. Davis |
Jackson Plagge |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
MICHAEL CONNOLLY |
MJMINC2000@AOL.COM |
Vice President |
Dallas Center |
Iowa |
United States |
Stephen L. Davis |
Jackson Plagge |
Signed |
183 |
2021-02-18 08:54 |
Anonymous (not verified) |
173.18.193.51 |
Freeman Family Farms Inc |
3125 Glasgow Rd Fairfield Iowa 52556 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-08 |
David Freeman |
jill@fullenkampins.com |
Fairfield |
Jefferson |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Freeman |
jill@fullenkampins.com |
President |
Fairfield |
Jefferson |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
182 |
2021-02-18 08:52 |
Anonymous (not verified) |
173.18.193.51 |
Freeman Family Farms Inc |
3125 Glasgow Rd Fairfield Iowa 52556 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-08 |
Bradly Freeman |
jill@fullenkampins.com |
Mt. Pleasant |
Henry |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradly Freeman |
jill@fullenkampins.com |
Treasurer |
Mt Pleasant |
Henry |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
181 |
2021-02-18 08:49 |
Anonymous (not verified) |
173.18.193.51 |
Freeman Family Farms Inc |
3125 Glasgow Rd Fairfield Iowa 52556 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-08 |
Phyllis Freeman |
jill@fullenkampins.com |
Fairfield |
Jefferson |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Phyllis Freeman |
bfree4020@gmail.com |
Secretary |
Fairfield |
Jefferson |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
180 |
2021-02-16 18:05 |
Anonymous (not verified) |
216.248.123.206 |
Outer Edge Screen Printing |
2449 68th Street Van Horne, Iowa 52346 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-16 |
Kimberly Sue Kline |
outedgekim@gmail.com |
Van Horne |
IA |
United States |
Amber Lynn Valentine |
Kelsea Marie Kline |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Outer Edge Screen Printing Co |
outedgekim@gmail.com |
Spouse |
Van Horne |
IA |
United States |
Amber Lynn Valentine |
Kelsea Marie Kline |
Signed |
179 |
2021-02-16 18:03 |
Anonymous (not verified) |
216.248.123.206 |
Outer Edge Screen Printing |
2449 68th Street Van Horne, Iowa 52346 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-16 |
Kyle Christopher Kline |
outedgekim@gmail.com |
Van Horne |
IA |
United States |
Kelsea Marie Kline |
Amber Marie Valentine |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kimberly Sue Kline |
outedgekim@gmail.com |
spouse |
Van Horne |
IA |
United States |
Kelsea Marie Kline |
Amber Lynn Valentine |
Signed |
178 |
2021-02-13 00:06 |
Anonymous (not verified) |
172.58.87.80 |
All Cut Lawncare and Landscaping LLC |
3506 Glover Ave. Des Moines Iowa 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-12 |
Michael David Money |
moneymichael811@gmail.com |
Des Moines |
Polk |
Iowa |
Diana Jennings |
Deanna L Phagan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael David Miney |
mineymichael811@gmail.com |
Owner and President |
Des Moines |
Polk |
Iowa |
Diana Jennings |
Deanna L Phagan |
Signed |
177 |
2021-02-03 15:07 |
Anonymous (not verified) |
174.198.90.166 |
Jesse's Embers LLC |
3301 Ingersoll Ave, Des Moines, IA, 50312 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-03 |
Martin Scarpino |
martyscarpino@yahoo.com |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Martin Scarpino |
martyscarpino@yahoo.com |
Owner |
Des Moines |
IA |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
176 |
2021-02-03 15:02 |
Anonymous (not verified) |
174.198.90.166 |
Jesse's Embers LLC |
3301 Ingersoll Ave, Des Moines, IA, 50312 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-03 |
Deena Edelstein |
dledelstein@hotmail.com |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Deena Edelstein |
dledelstein@hotmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
175 |
2021-02-01 11:20 |
Anonymous (not verified) |
216.51.132.207 |
VONDERHAAR CONSTRUCTION |
33181 OSTERDOCK RD GUTTENBERG IA 52052 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-28 |
ROBIE VONDERHAAR |
nicole@cioia.com |
GUTTENBERG |
CLAYTON |
IA |
JERRY J ROCHFORD |
NICOLE L PARKER |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ROBIE VONDERHAAR |
NICOLE@CIOIA.COM |
OWNER |
Guttenberg |
CLAYTON |
IA |
JERRY J ROCHFORD |
NICOLE L PARKER |
Signed |
174 |
2021-01-29 12:08 |
Anonymous (not verified) |
108.174.118.195 |
Tempered Solutions HVAC LLC |
897 Old Corvallis Road |
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. |
2021-01-29 |
Zachery Wiediger |
temperedsolutionshvac@gmail.com |
Corvallis |
Montana |
United States |
Julie R. Ostrenga |
Douglas M. Ostrenga |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Zachery Wiediger |
temperedsolutionshvac@gmail.com |
Self |
Corvallis |
Montana |
United States |
Douglas M. Ostrenga |
Julie R. Ostrenga |
Signed |
173 |
2021-01-26 19:29 |
Anonymous (not verified) |
173.17.84.174 |
Robert Schroeder const. inc |
10984 150 th. st. davenport ia. 52804 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-26 |
ROBERT SCHROEDER |
r.schroeder@aol.com |
davenport |
scott |
ia. |
Debra Blaser |
John Ekin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ROBERT SCHROEDER |
r.schroeder@aol.com |
President |
davenport |
scott |
ia. |
Debra Blaser |
John Ekin |
Signed |
172 |
2021-01-26 19:02 |
Anonymous (not verified) |
173.17.8.56 |
Hutch's Parking Lot Sweeping |
5235 JENNIFER DR |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-26 |
Bill HUTCHINSON |
btnwhutch@aol.com |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
WHITNIE HUTCHINSON |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill HUTCHINSON |
btnwhutch@aol.com |
Self |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
WHITNIE HUTCHINSON |
Signed |
171 |
2021-01-26 15:07 |
Anonymous (not verified) |
174.198.73.28 |
R. A. Snow Removals, Inc |
525 7th St. 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. |
2021-01-26 |
Robert Aaron Snow |
rasnowremovals.inc@gmail.com |
Altoona |
Polk |
Iowa |
Shannon Keely Moses |
Jessy James Dentler |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Aaron Snow |
rasnowremovals.inc@gmail.com |
President |
Altoona |
Polk |
Iowa |
Shannon Keely Moses |
Jessy James Dentler |
Signed |
170 |
2021-01-26 12:23 |
Anonymous (not verified) |
74.84.91.178 |
Sunset Ridge Winery LLC |
12615 Highway 52 North, Dubuque, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-07 |
Ann Bonnette |
jbonnette@yahoo.com |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ann Bonnette |
jbonnette@yahoo.com |
Officer |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
169 |
2021-01-26 12:20 |
Anonymous (not verified) |
74.84.91.178 |
Sunset Ridge Winery LLC |
12615 Highway 52 North, Dubuque, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-07 |
John Bonnette |
jbonnette@yahoo.com |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Bonnette |
jbonnette@yahoo.com |
Officer |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
168 |
2021-01-26 12:06 |
Anonymous (not verified) |
74.84.91.178 |
RAM Services |
13276 Harvest Mood Ridge, Sherrill, IA 52073 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-11 |
Dusty Herbst |
dustyherbst@hotmail.com |
Sherrill |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dusty Herbst |
dustyherbst@hotmail.com |
President |
Sherrill |
Dubuque |
Iowa |
Derrick Parsons |
Brenda Lewis |
Signed |
167 |
2021-01-26 11:56 |
Anonymous (not verified) |
74.84.91.178 |
Shea Real Estate LLC |
135 Devon Drive, Dubuque, IA 52001 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-17 |
Lucas Kahl |
shearealestatellc@gmail.com |
Dubuque |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lucas Kahl |
shearealestatellc@gmail.com |
President |
Dubuque |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
166 |
2021-01-21 08:52 |
Anonymous (not verified) |
66.102.212.10 |
English River Transport, Inc. |
2015 Highway 22, Kalona, IA 52247 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-13 |
James A Yoder |
fisheria@kctc.net |
Kalona |
Washington |
IA |
Christian Swartzentruber |
Judy Showalter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James A Yoder |
christian@fisherins.com |
President |
Kalona |
Washington |
IA |
Christian Swartzentruber |
Judy Showalter |
Signed |
165 |
2021-01-20 11:14 |
Anonymous (not verified) |
173.233.46.58 |
Wasmer Post 241, Department of Iowa dba The American Legion |
110 Plymouth St SW, Le Mars, IA 51031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-13 |
Matthew Larson |
mrkmjm@yahoo.com |
Alton |
Sioux |
IA |
Muriel J. Miller |
Richard P. Miller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gary L. Konz |
claim_buster@yahoo.com |
Financial Officer |
Le Mars |
Plymouth |
IA |
Muriel J. Miller |
Richard P. Miller |
Signed |
164 |
2021-01-20 11:11 |
Anonymous (not verified) |
173.233.46.58 |
Wasmer Post 241, Department of Iowa dba The American Legion |
110 Plymouth St SW, Le Mars, IA 51031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-13 |
Andrew M. Schultze |
mrkmjm@yahoo.com |
Le Mars |
Plymouth |
IA |
Muriel J. Miller |
Richard P. Miller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gary L. Konz |
claim_buster@yahoo.com |
Financial Officer |
Le Mars |
Plymouth |
IA |
Muriel J. Miller |
Richard P. Miller |
Signed |
163 |
2021-01-20 11:08 |
Anonymous (not verified) |
173.233.46.58 |
Wasmer Post 241 Department of Iowa dba The American Legion |
110 Plymouth St SW, Le Mars, IA 51031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-13 |
Kim Wittmar |
mrkmjm@yahoo.com |
Le Mars |
Plymouth |
iA |
Muriel J. MIller |
Richard P. Miller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gary L. Konz |
claim_buster@yahoo.com |
Financial Officer |
Le Mars |
Plymouth |
IA |
Muriel J. Miller |
Richard P. Miller |
Signed |
162 |
2021-01-19 15:21 |
Anonymous (not verified) |
72.255.74.171 |
JD Enterprises Inc |
4807 160th Ave, Carlisle, IA 50047 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-19 |
Jim Downs |
jdowns@arrowisg.com |
Carlisle |
Warren |
Iowa |
Tyler Cataldo |
Patti Isley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jim Downs |
jdowns@arrowisg.com |
Owner |
Carlisle |
Warren |
Iowa |
Tyler Cataldo |
Patti Isley |
Signed |
161 |
2021-01-14 19:19 |
Anonymous (not verified) |
108.174.118.195 |
Four Seasons HVAC LLC |
3165 Four Seasons Drive, Stevensville, MT 59870 |
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. |
2021-01-14 |
Douglas Michael Ostrenga |
doug@fourseasonshvac.com |
Stevensville |
Ravalli |
MT |
Zachery Donald Wiediger |
Thomas Maximillian Liedtka |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Julie Ruthanne Ostrenga |
julie@fourseasonshvac.com |
Member Manager |
Stevensville |
Ravalli |
MT |
Zachery Donald Wiediger |
Thomas Maximillian Liedtka |
Signed |
160 |
2021-01-13 10:52 |
Anonymous (not verified) |
173.190.64.239 |
united workers inc |
711 4th st ne |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-13 |
mayra sapolvada |
buck@trvnet.net |
Belmond |
wright |
iowa |
shannon muhlenbruch |
Martha Leal |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
mayra sapulvada |
buck@trvnet.net |
president |
belmond |
wright |
ia |
shannon myhlenbruch |
martha leal |
Signed |
159 |
2021-01-12 09:00 |
Anonymous (not verified) |
72.13.20.192 |
RTA TRUCKING LLC |
31504 E Worthington Rd, 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. |
2020-01-12 |
Kirk Pleggenkuhle dba Pleggenkuhle Pride Inc. |
kirkpleggenkuhle@gmail.com |
Mingo |
Jasper |
IA |
Rod Jaeger |
Jennie Jaeger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jennie Jaeger |
rtatruck@gmail.com |
office manager |
Worthington |
IA |
United States |
Rod Jaeger |
Kirk Pleggenkuhle |
Signed |
158 |
2021-01-06 15:54 |
Anonymous (not verified) |
216.81.153.249 |
Al's Inc DWB CW&T |
1509 Richland Drive, Storm Lake, IA 5058 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-29 |
Julie Deucker |
NONE@GMAIL.COM |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Julie Duecker |
None@gmail.com |
Owner |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
157 |
2021-01-06 15:53 |
Anonymous (not verified) |
216.81.153.249 |
Al's Inc DWB CW&T |
1509 Richland Drive, Storm Lake, IA 5058 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-29 |
April Coleman |
NONE@GMAIL.COM |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
April Coleman |
None@gmail.com |
Owner |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
156 |
2021-01-06 15:52 |
Anonymous (not verified) |
216.81.153.249 |
Al's Inc DWB CW&T |
1509 Richland Drive, Storm Lake, IA 5058 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-29 |
Jon Bauer |
NONE@GMAIL.COM |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jon Bauer |
None@gmail.com |
Owner |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
155 |
2021-01-06 15:50 |
Anonymous (not verified) |
216.81.153.249 |
Al's Inc DWB CW&T |
1509 Richland Drive, Storm Lake, IA 5058 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-29 |
Robert Bauer |
NONE@GMAIL.COM |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Bauer |
NONE@GMAIL.COM |
Owner |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
154 |
2021-01-06 13:23 |
Anonymous (not verified) |
167.142.147.6 |
PACIFIC DRYWALL CORPORATION |
105 SNYDER DRIVE HUXLEY, IOWA 50124 |
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. |
2021-01-06 |
LUIS MANUEL AVALOS CASTELANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
DES MOINES |
POLK |
IOWA |
JENNIFER LYNNE ESCOBAR |
JUAN JOSE AVALOS CASTELLANOS |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
LUIS MANUEL AVALOS CASTELANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
PRESIDENT |
DES MOINES |
POLK |
IOWA |
JUAN JOSE AVALOS CASTELLANOS |
JENNIFER LYNNE ESCOBAR |
Signed |
153 |
2021-01-06 13:20 |
Anonymous (not verified) |
167.142.147.6 |
PACIFIC DRYWALL CORPORATION |
105 SNYDER DRIVE HUXLEY, IOWA 50124 |
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 |
JUAN JOSE AVALOS CASTELLANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
ANKENY |
POLK |
IOWA |
JENNIFER LYNNE ESCOBAR |
LUIS MANUEAL AVALOS CASTELANOS |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
JUAN JOSE AVALOS CASTELLANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
VICE PRESIDENT |
ANKENY |
POLKC |
IOWA |
JENNIFER LYNNE ESCOBAR |
LUIS MANUEL AVALOS CASTELANOS |
Signed |
152 |
2021-01-04 12:08 |
Anonymous (not verified) |
104.129.206.120 |
Schleswig Transfer Inc |
216 Valley View Dr, Schleswig, IA 51461 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-11-30 |
Wade Miller |
t.uhl3@joemorten.com |
Schleswig |
Crawford |
Iowa |
Tamara Uhl |
Amy Meseck |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Wade Miller |
t.uhl3@joemorten.com |
President |
Schleswig |
Crawford |
IA |
Tamara Uhl |
Amy Meseck |
Signed |
151 |
2021-01-01 11:26 |
Anonymous (not verified) |
75.162.130.160 |
The Product Boss LLC |
20 Mountain Way, West Orange, NJ 07052 |
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. |
2021-01-01 |
Minna Khounlo-Sithep |
minna@theproductboss.com |
Ankeny |
IA |
IA |
Nalinh Sithep |
Suzzan Khounlo |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Minna Khounlo-Sithep |
minnaks@gmail.com |
Co-Owner |
Ankeny |
IA |
IA |
Nalinh Sithep |
Suzzan Khounlo |
Signed |