143 |
2020-12-02 09:43 |
Anonymous (not verified) |
208.90.15.53 |
Humboldt Community Daycare, Inc. DBA Kiddie Cats Childcare and Learning Center |
P.O. Box 93 Dakota City, Ia 50529 |
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. |
2020-12-02 |
Rob Dickey |
robd@fsbwc.com |
Gilmore City |
Humboldt |
Iowa |
Ross Sleiter |
Scott Curran |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rob Dickey |
robd@fwbwc.com |
Vice President |
Gilmore City |
Humboldt |
Iowa |
Ross Sleiter |
Scott Curran |
Signed |
142 |
2020-12-02 09:39 |
Anonymous (not verified) |
208.90.15.53 |
Humboldt Community Daycare, Inc. DBA Kiddie Cats Childcare and Learning Center |
P.O. Box 93 Dakota City, Ia 50529 |
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. |
2020-12-02 |
Angelique Berry |
dcity@goldfieldaccess.net |
Algona |
Kossuth |
Iowa |
Ross Sleiter |
Scott Curran |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Angelique Berry |
dcity@goldfieldaccess.net |
Secretary/Treasurer |
Algona |
Kossuth |
Iowa |
Ross Sleiter |
Scott Curran |
Signed |
141 |
2020-12-02 09:34 |
Anonymous (not verified) |
208.90.15.53 |
Humboldt Community Daycare, Inc. DBA Kiddie Cats Childcare and Learning Center |
P.O. Box 93 Dakota City, Ia 50529 |
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. |
2020-12-02 |
Travis Goedken |
travisg@cityofhumboldt.org |
Humboldt |
Humboldt |
Iowa |
Ross Sleiter |
Lance Dewinter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis Goedken |
travisg@cityofhumboldt.org |
President |
Humboldt |
Humboldt |
Iowa |
Ross Sleiter |
Lance Dewinter |
Signed |
140 |
2020-11-25 12:43 |
Anonymous (not verified) |
63.152.43.202 |
All Heart Staffing, Inc. |
4403 1ST AVE. SE, SUITE 310, CEDAR RAPIDS, IA 52402 |
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. |
2020-11-01 |
Joel Katcher |
Joel@AllHeartStaffing.com |
CEDAR RAPIDS |
IA |
United States |
Andy Becker |
Kathryn Brown |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joel Katcher |
Joel@AllHeartStaffing.com |
President |
CEDAR RAPIDS |
IA |
United States |
Andy Becker |
Kathryn Brown |
Signed |
139 |
2020-11-24 15:45 |
Anonymous (not verified) |
174.219.2.33 |
Dan Petersen Construction LLC |
1725 South 14th St, Polk City, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-11-24 |
Daniel Petersen |
danpetersenconstruction@gmail.com |
Polk City |
Polk |
Iowa |
Erik Gramenz |
Jim McMurray |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Petersen |
danpetersenconstruction@gmail.com |
Owner |
Polk City |
Polk |
Iowa |
Erik Gramenz |
Jim McMurray |
Signed |
138 |
2020-11-24 14:11 |
Anonymous (not verified) |
173.215.17.41 |
Dohrmann Enterprises, Inc |
2478 260th Ave. DeWitt, Iowa 52742 |
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. |
2020-11-24 |
Joel Dohrmann |
dohrmannpnh@gmail.com |
DE WITT |
Clinton |
IA |
Susanne Owen |
Daron Oberbroecking |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Susanne Owen |
sowen@ohnward.com |
none |
Camanche |
Clinton |
Iowa |
Joel Dohrmann |
Daron Oberbroecking |
Signed |
137 |
2020-11-23 10:11 |
Anonymous (not verified) |
207.32.14.70 |
Community Ambulance Service, Inc. |
15 N 1st St., 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. |
2020-11-18 |
Christopher Fuhrman |
christopher.furhrman@edwardjones.com |
Spirit Lake |
Dickinson |
Iowa |
Sara M Fisher |
Abbie J Fuhrman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher Fuhrman |
christopher.fuhrman@edwardjones.com |
President |
Spirit Lake |
Dickinson |
Iowa |
Sara M Fisher |
Abbie J Fuhrman |
Signed |
136 |
2020-11-20 11:06 |
Anonymous (not verified) |
208.95.1.97 |
Burds Communities Inc. |
606 S 3rd Street, Bellevue, IA 52031 |
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. |
2020-11-20 |
Tim Burds |
burdshousing@yahoo.com |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tim Burds |
burdshousing@yahoo.com |
Vice President |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
135 |
2020-11-20 11:05 |
Anonymous (not verified) |
208.95.1.97 |
Burds Communities Inc. |
606 S 3rd Street, Bellevue, IA 52031 |
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. |
2020-11-20 |
Todd Burds |
burdshousing@yahoo.com |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Todd Burds |
burdshousing@yahoo.com |
President |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
134 |
2020-11-16 16:36 |
Anonymous (not verified) |
192.33.191.131 |
Nekola Outdoors Services, Inc |
722 Penrose St, Grinnell IA 50112 |
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. |
2020-11-16 |
Matthew Lee Nekola |
NEKOLAOUTDOORSERVICES@GMAIL.COM |
Grinnell |
Poweshiek |
Iowa |
Josh Lacaeyse |
Frank Heinen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Matthew Lee Nekola |
nekolaoutdoorservices@gmail.com |
President |
Grinnell |
Poweshiek |
Iowa |
Josh Lacaeyse |
Frank Heinen |
Signed |
133 |
2020-11-15 19:57 |
Anonymous (not verified) |
75.162.166.182 |
A Metro Snow Removal and lawn care llc |
6436 Washington Ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-11-15 |
Jeff Lamp |
Jeff.lamp79@gmail.com |
Windsor hieghts |
IA |
United States |
Jill Fresh |
Rick Brown |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
A Metro Snow Removal and lawn Care llc |
Jeff.lamp79@gmail.com |
Owner |
Windsor hieghts |
IA |
United States |
jill Fresh |
Rick Brown |
Signed |
132 |
2020-11-03 13:22 |
Anonymous (not verified) |
173.22.125.16 |
BeraTek Industries |
407 9th Ave SE, Cedar Rapids, IA 52401 |
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. |
2020-11-03 |
Ethan Davidson |
edavidson@beratek-industries.com |
Cedar Rapids |
Linn |
Iowa |
Raymond Gerald Beranek |
Ethan Paul Davidson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ethan Paul Davidson |
edavidson@beratek-industries.com |
President |
Cedar Rapids |
Linn |
Iowa |
Raymond Gerald Beranek |
Ethan Paul Davidson |
Signed |
131 |
2020-11-03 10:26 |
Anonymous (not verified) |
207.32.1.185 |
Little Bison Childcare Center |
404 2nd ST NW Buffalo Center, IA. 50424 |
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. |
2020-11-03 |
Megan C Holland |
megzholland@live.com |
Buffalo Center |
Winnebago |
Iowa |
Nicholas D Holland |
Emily J Angstman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Megan C Holland |
megzholland@live.com |
Vice President |
Buffalo Center |
Winnebago |
Iowa |
Nicholas D Holland |
Emily J Angstman |
Signed |
130 |
2020-11-02 12:40 |
Anonymous (not verified) |
67.55.220.86 |
Little Bison Childcare Center |
404 2nd St NW, Buffalo Center, IA 50424 |
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. |
2020-11-02 |
Joseph Robert Angstman |
angstman.joe@gmail.com |
Buffalo Center |
Winnebago |
Iowa |
Emily Jean Thomsen Angstman |
Pamela Kay Angstman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Robert Angstman |
angstman.joe@gmail.com |
Secretary |
Buffalo Center |
Winnebago |
Iowa |
Emily Jean Thomsen Angstman |
Pamela Kay Angstman |
Signed |
129 |
2020-10-30 11:23 |
Anonymous (not verified) |
184.80.177.137 |
Haberdash Outfitters, Inc. |
109 1st Ave East - Dyersville, IA 52040 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-10-27 |
Jennifer Recker |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
128 |
2020-10-29 07:51 |
Anonymous (not verified) |
74.84.91.178 |
J & J Drywall LLC |
1277 Elm Street |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-10-27 |
Jeff Frick |
frickdbq@gmailc.com |
Dubuque |
Dubuque |
IA |
Brenda Lewis |
Gabe Drewelow |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeff Frick |
frickdbq@gmailc.com |
president |
Dubuque |
Dubuque |
Iowa |
Brenda Lewis |
Gabe Drewelow |
Signed |
127 |
2020-10-28 14:42 |
Anonymous (not verified) |
104.207.31.201 |
Little Bison Childcar Center, Inc. |
404 2nd 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. |
2020-10-28 |
Travis Brass |
travis.brass@rakestatesavingsbank.com |
Lakota |
Kossuth |
Iowa |
Tami Jacobson |
Carol Winter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis Brass |
travis.brass@rakestatesavingsbank.com |
Treasurer |
Lakota |
Kossuth |
Iowa |
Tami Jacobson |
Carol Winter |
Signed |
126 |
2020-10-28 14:31 |
Anonymous (not verified) |
104.207.25.44 |
Little Bison Daycare Center |
404 2nd St. NW Buffalo Center, IA 50424 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-10-28 |
Cody Tyler Wirtjes |
cody@afschem.com |
Buffalo Center |
Winnebago |
Iowa |
Michael James Perkins |
Garrett Alan Asmus |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cody Tyler Wirtjes |
cody@afschem.com |
Board President |
Buffalo Center |
Winnebago |
Iowa |
Michael James Perkins |
Garrett Alan Asmus |
Signed |
125 |
2020-10-26 16:33 |
Anonymous (not verified) |
162.253.44.212 |
Gutter Filter Specialists Inc |
1805 Red Fox Way Marion, IA 52302 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-10-26 |
Richard L Mellor |
rickmellor88@gmail.com |
Marion |
Linn |
IA |
Katie Luehrsmann |
Melissa Lown |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Richard L Mellor |
rickmellor88@gmail.com |
President |
Marion |
Linn |
IA |
Katie Luehrsmann |
Melissa Lown |
Signed |
124 |
2020-10-21 14:07 |
Anonymous (not verified) |
173.23.249.165 |
Madison County Auction Company LLC |
1204 West Summit Winterset, IA 50273 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-10-09 |
Tim Gomez |
tjagomez@gmail.com |
Winterset |
Madison |
Iowa |
Sheena Earles |
Russell Boggs |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Russell Boggs |
Russell.Boggs@fbfs.com |
None |
St Charles |
madison |
iowa |
Sheena Earles |
Russell Boggs |
Signed |
123 |
2020-10-20 17:35 |
Anonymous (not verified) |
66.172.250.9 |
Ladwig Constrution |
509 Moorehead St. Ida Grove, IA 51445 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-10-20 |
Ross Ladwig |
rossladwig@gmail.com |
Ida Grove |
Ida |
Iowa |
Christine Ladwig |
Kya Ladwig |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Ross Ladwig |
rossladwig@gmail.com |
Owner |
Ida Grove |
Ida |
Iowa |
Christine Ladwig |
Kya Ladwig |
Signed |
122 |
2020-10-05 15:21 |
Anonymous (not verified) |
173.24.190.134 |
Greg Haldin Construction, Inc. |
PO Box 387, Sioux Rapids, IA 50585 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-10-06 |
Greg Haldin |
ghconstruction@live.com |
Sioux Rapids |
Buena Vista |
IA |
Candie Clark |
Scott Wirtz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Greg Haldin |
ghconstruction@live.com |
President |
Sioux Rapids |
Buena Vista |
IA |
Candie Clark |
Scott Wirtz |
Signed |
121 |
2020-10-01 09:40 |
Anonymous (not verified) |
50.82.176.77 |
Kinion Towing Inc. |
100 Industrial Park Drive, Clarence, IA 52216 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-30 |
Adam Kinion |
kinionas@yahoo.com |
Tipton |
Cedar |
Iowa |
Michael Blake |
Jeffrey Case |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Kinion |
kinionas@yahoo.com |
Vice President |
Tipton |
Cedar |
Iowa |
Michael Blake |
Jeffrey Case |
Signed |
120 |
2020-10-01 09:34 |
Anonymous (not verified) |
50.82.176.77 |
Kinion Towing Inc. |
100 Industrial Park Drive, Clarence, IA 52216 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-30 |
Dale Kinion |
kinionas@yahoo.com |
Monmouth |
Jones |
Iowa |
Michael Blake |
Jeffrey Case |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dale Kinion |
kinionas@yahoo.com |
President |
Monmouth |
Jones |
Iowa |
Michael Blake |
Jeffrey Case |
Signed |
119 |
2020-09-28 10:43 |
Anonymous (not verified) |
174.213.149.6 |
Ddp construction |
1923 63rd st, des moines ,ia 50322 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-28 |
Dustin a perry |
perrythedustin@gmail.com |
Urbandale |
Polk |
Iowa |
Lucas jackson |
Cody roth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Smith Kenyon insurance |
smithkenyon@yahoo.com |
Agent |
Urbandale |
Polk |
Ia |
Lucas jackson |
Cody roth |
Signed |
118 |
2020-09-15 14:32 |
Anonymous (not verified) |
174.243.115.133 |
Jurisdiction Approved Plumbing Corporation |
P.O. Box 343 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-15 |
Christian m Lavia |
eeejumble@gmail.com |
Urbandale |
Polk |
Iowa |
Tina m Heuckendorf |
Roslyn Heuckendorf |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christian m Lavia |
eeejumble@gmail.com |
Director |
Urbandale |
Polk |
IOWA |
Tina m Heuckendorf |
Roslyn Heukendorf |
Signed |
117 |
2020-09-11 11:54 |
Anonymous (not verified) |
162.218.1.22 |
american business resource corporation |
4600 American Parkway Suite #301 Madison, WI 53718 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-11 |
Michelle Szabrowicz |
mszabrowicz@abrjobs.com |
Madison |
Dane |
Wisconsin |
Patricia Haggerty |
Britney Mollet |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michelle Szabrowicz |
mszabrowicz@abrjobs.com |
CFO |
Madison |
Dane |
Wisconsin |
Patricia Haggerty |
Britney Mollet |
Signed |
116 |
2020-09-11 11:42 |
Anonymous (not verified) |
69.57.22.68 |
Brush and Weed Control Specialists, Inc. |
1108 230th Street - Algona, IA 50511 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-11 |
Ruth Jean Lindgren |
bwcontrol@netamumail.com |
Algona |
Kossuth |
Iowa |
James Black |
Katie Melvin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Donald H Reffer |
bwcontrol@netamumail.com |
President and General Manager |
Algona |
Kossuth |
Iowa |
James Black |
Katie Melvin |
Signed |
115 |
2020-09-08 09:48 |
Anonymous (not verified) |
184.80.177.137 |
Beyond Builders LLC |
206 Culver Road NE, Hopkinton, IA 52237 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-08 |
John Eiben |
ginger_bread_man@msn.com |
HOPKINTON |
Delaware |
IA |
Derrick Parsons |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Eiben |
ginger_bread_man@msn.com |
Owner |
Hopkinton |
Delaware |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
114 |
2020-09-04 13:11 |
Anonymous (not verified) |
107.182.207.0 |
KEITH N SLYTER |
PO 2632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-04 |
KEITH N SLYTER |
KNSCONST@GMAIL.COM |
DAVENPORT |
25|IA |
iowa |
KEITH N SLYTER |
KEITH N SLYTER |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
KEITH N SLYTER |
KNSCONST@GMAIL.COM |
owner |
DAVENPORT |
25|IA |
iowa |
KEITH N SLYTER |
KEITH N SLYTER |
Signed |
113 |
2020-09-03 14:22 |
Anonymous (not verified) |
72.255.74.171 |
James Raymond and Associates Inc |
240 S 1st St, 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. |
2020-09-03 |
Jim Downs |
jdowns@arrowisg.com |
Carlisle |
Warren |
Iowa |
TJ Cataldo |
Patti Isley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jim Downs |
jdowns@arrowisg.com |
Owner |
Carlisle |
Warren |
Iowa |
TJ Cataldo |
Patti Isley |
Signed |
112 |
2020-08-26 10:18 |
Anonymous (not verified) |
97.64.131.90 |
BNR Construction INC |
210 4th St Orient, IA 50858 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-15 |
Bennie Shinn |
bnrconstllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
111 |
2020-08-25 14:37 |
Anonymous (not verified) |
204.155.61.217 |
BNR Construction INC |
210 4th St Orient,Ia 50858 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-15 |
Bennie Shinn |
bnrconstructllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstructllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
110 |
2020-08-25 14:31 |
Anonymous (not verified) |
199.241.229.222 |
Ney Trucking Inc |
5070 Wolff Rd 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. |
2020-08-25 |
Marvin L Ney |
marvin@paramountems.com |
Peosta |
Dubuque |
Iowa |
Karen Ludovissy |
Brenda Weatherwax |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Maria A Ney |
maria@paramountems.com |
Secretary |
Peosta |
Dubuque |
IA |
Karen Ludovissy |
Brenda Weatherwax |
Signed |
109 |
2020-08-24 14:41 |
Anonymous (not verified) |
74.84.91.178 |
Rotten Love LLC |
1101 Valentine Drive, Dubuque, IA 52003 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-08-14 |
Carolyn Schmid |
rottenlovellc@gmail.com |
Dubuque |
Dubuque |
Iowa |
Brenda Lewis |
Sue Miller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carolyn Schmid |
rottenlovellc@gmail.com |
partner |
Dubuque |
Dubuque |
IA |
Brenda Lewis |
Sue Miller |
Signed |
108 |
2020-08-19 09:39 |
Anonymous (not verified) |
184.80.177.137 |
Michelle's Vocational Placement LLC |
2642 Farragut Pl., 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. |
2020-08-18 |
Tara Rommel |
jheims@engish-insurance.com |
Davenport |
Scott |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
107 |
2020-08-04 13:42 |
Anonymous (not verified) |
97.64.131.90 |
BNR Construction INC |
210 4th St Orient, IA 50858 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-08-04 |
Bennie Shinn |
bnrconstllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
106 |
2020-07-27 12:12 |
Anonymous (not verified) |
206.125.132.254 |
Pacos Roofing Inc |
837 Lynkaylee Dr Waterloo, IA 50701 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-27 |
Blanca Garcia |
Pacosroofing@outlook.com |
Waterloo |
Black Hawk |
Iowa |
Kaitlin Schepers |
Sarah Whalen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Blanca Garcia |
Pacosroofing@outlook.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Kaitlin Schepers |
Sarah Whalen |
Signed |
105 |
2020-07-24 18:21 |
Anonymous (not verified) |
74.115.101.23 |
Humboldt County Agricultural Society |
311 N 6th Ave P.O. Box 391, Humboldt, IA 50548 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-24 |
Kevin Cordray |
kwcordray@gmail.com |
Humboldt |
Humboldt |
IA |
Marva Anderson |
Jeff Halverson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Humboldt County Agricultural Society |
info@humboldtcountyfair.com |
Business Manager |
Humboldt |
Humboldt |
IA |
Marva Anderson |
Jeff Halverson |
Signed |
104 |
2020-07-24 10:07 |
Anonymous (not verified) |
173.24.248.4 |
Dirty 30 Trucking & Excavating |
3018 Lawnview Drive |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-24 |
Kirkland Davidson |
dirty30iowa@gmail.com |
Mt. Ayr |
Ringgold |
Iowa |
Alexandra Peace |
Rahim Martin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kirkland Davidson |
dirty30iowa@gmail.com |
President |
Des Moines |
Polk |
Iowa |
Alexandra Peace |
Rahim Martin |
Signed |
103 |
2020-07-23 09:23 |
Anonymous (not verified) |
184.80.177.137 |
Jacob Reiff |
15738 N Cascade Rd - Peosta, IA 52068 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2020-07-23 |
Jacob Reiff |
jheims@engish-insurance.com |
Peosta, |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
owner |
Peosta |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
102 |
2020-07-19 14:42 |
Anonymous (not verified) |
208.90.8.234 |
Humboldt County Agricultural Society |
311 N 6th Ave P.O. Box 391, Humboldt, IA 50548 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-19 |
Paul Davis |
dfs72@yahoo.com |
Humboldt |
Humboldt |
IA |
Marva Anderson |
Paul Davis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Humboldt County Agricultural Society |
info@humboldtcountyfair.com |
Business Manager |
Humboldt |
81 |
IA |
Marva Anderson |
Jeff Halverson |
Signed |
101 |
2020-07-16 13:07 |
Anonymous (not verified) |
173.28.28.57 |
Weikert Properties, LLC |
34520 175th Street, Cedar Falls IA 5061 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-06-23 |
Caleb Weikert |
cmins_re@mchsi.com |
Cedar Falls |
Grundy |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Caleb Weikert |
cmins_re@mchsi.com |
Self |
Cedar Falls |
Grundy |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
100 |
2020-07-14 19:08 |
Anonymous (not verified) |
208.90.8.234 |
Humboldt County Agricultural |
311 N 6th Ave, P.O. Box 391, Humboldt, IA 50548 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-18 |
Jeff Haselhuhn |
gjhaselhuhn@gmail.com |
Humboldt |
Humboldt |
IA |
Marva Anderson |
Jeff Halverson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marva Anderson |
info@humboldtcountyfair.com |
Business Manager |
Humboldt |
81 |
81 |
Marva Anderson |
Jeff Halverson |
Signed |
99 |
2020-07-12 13:29 |
Anonymous (not verified) |
207.32.58.202 |
Subject Enterprise, Inc. |
165 210th St Wesley, IA 50483 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-12 |
Coda Subject |
subjectenterprise@gmail.com |
Britt |
Hancock |
IA |
Keri Byom |
Steve Schlichting |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Coda Subject |
subjectenterprise@gmail.com |
Owner |
Britt |
Hancock |
IA |
Keri Byom |
Steve Schlichting |
Signed |
98 |
2020-07-11 16:34 |
Anonymous (not verified) |
50.83.184.81 |
Paradigm Construction LLC |
1847 nw 90th st Clive, IA 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-06 |
Jonathon Richard Curtis |
joncurtis15@gmail.com |
Des Moines |
Polk |
IA |
Yolanda Curtis |
Susan Brooker |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Ryan Shabino |
ryan@prdgmconstruction.com |
Contractor |
Clive |
Polk |
IA |
Yolanda Curtis |
Susan Brooker |
Signed |
97 |
2020-07-09 10:07 |
Anonymous (not verified) |
173.215.13.54 |
LOS DOS MEXICAN RESTAURANT DBA CASA DE ORO |
1211 2ND ST, PERRY IOWA 50220 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-05-01 |
MARIO LEPE |
DAVID.FINNESETH@FBFS.COM |
PERRY |
DALLAS |
IOWA |
ROBERTA L GILSON |
SANDRA S WHEELER |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
MARIO LEPE |
DAVID.FINNESETH@FBFS.COM |
VICE PRESIDENT |
PERRY |
DALLAS |
IOWA |
ROBERTA L GILSON |
SANDRA S WHEELER |
Signed |
96 |
2020-07-03 16:51 |
Anonymous (not verified) |
208.90.8.234 |
Humboldt Co. Ag Society |
311 6th Ave. N Humboldt IA. |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-03 |
Jeffrey D. Halverson |
roadgear54@yahoo.com |
Hardy |
Humboldt |
Iowa |
Marva Anderson |
Paul Davis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey Halverson |
roadgear54@yahoo.com |
Vice President |
Hardy |
Humboldt |
Iowa |
Marva Anderson |
Paul Davis |
Signed |
95 |
2020-07-02 10:30 |
Anonymous (not verified) |
206.125.132.254 |
Dave Prochaska Construction |
5848 Hopeview Ct |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-02 |
Dave Prochaska |
kschepers@nelsonbrothersagency.com |
Bettendorf |
Scott |
IA |
Kaitlin Schepers |
Lori Fisher |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave Prochaska |
kschepers@nelsonbrothersagency.com |
Owner |
Bettendorf |
Scott |
IA |
Kaitlin Schepers |
Lori Fisher |
Signed |
94 |
2020-07-02 08:19 |
Anonymous (not verified) |
174.217.21.87 |
James Subcontracting |
5212 South Union st. |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-02 |
James Lee Wardell |
jlw21479@gmail.com |
Des Moines |
IA |
United States |
Tammy Wardell |
Bobby Hoch |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Subcontracting |
jlw21479@gmail.com |
Owner |
Des Moines |
IA |
United States |
Tammy Wardell |
Bobby Hoch |
Signed |