540 |
2022-09-22 18:48 |
Anonymous (not verified) |
172.58.84.145 |
José j Castañeda lara |
1722 22st Des Moines iowa 50310 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-09-22 |
José j Castañeda lara |
jesuscastaneda28@gmail.com |
Des Moines |
Polk |
Iowa |
Joseph Powell |
Jesica Powell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
José j Castañeda lara |
jesuscastaneda28@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Joseph Powell |
Jesica Powell |
Signed |
652 |
2023-04-17 16:23 |
Anonymous (not verified) |
94.188.205.177 |
alternative sport enterprises llc |
506 6th st coralville IA 52241 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-17 |
nick carroll |
nick.carroll@mchsi.com |
Coralville |
IA |
United States |
Kaylyn Olson |
Jake Braman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
nick carroll |
nick.carroll@mchsi.com |
owner |
Coralville |
IA |
United States |
Kaylyn Olson |
Jake Braman |
Signed |
764 |
2023-09-10 19:18 |
Anonymous (not verified) |
94.188.205.177 |
Heartland Ultrasonography Group |
1015 Woodland Drive Carlisle, Iowa 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. |
2023-09-10 |
Bradley C Curtis |
blc735@msn.com |
Carlisle |
Warren |
Iowa |
Dane Joseph Wright |
Michael Lee Guffey |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley C Curtis |
Heartlandusgroup@outlook.com |
Co-owner llc |
Carlisle |
Warren |
Iowa |
Dane Joseph Wright |
Michael Lee Guffey |
Signed |
971 |
2024-05-03 07:33 |
Anonymous (not verified) |
94.188.205.176 |
Outdoor Pros LLC |
6535 WAPSI AVE SE Lone Tree IA 52755 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-02 |
Erik Alberhasky |
erikalberhas@gmail.com |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik Alberhasky |
erikalberhas@gmail.com |
Owner |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
876 |
2024-01-30 17:55 |
Anonymous (not verified) |
94.188.207.230 |
Erik Mortens |
9823 nw 46th ct polk city iowa 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. |
2024-01-30 |
Erik mortens |
Erik.mortens@gmail.com |
Polk city |
Polk |
Iowa |
Andrea Davis |
Kali Davis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik mortens |
Erik.mortens@gmail.com |
Self |
Polk city |
Polk |
Iowa |
Kali Davis |
Andrea Davis |
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 |
220 |
2021-03-29 08:07 |
Anonymous (not verified) |
173.18.193.51 |
Lee County Fair, Inc |
PO Box 179, Donnellson, 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. |
2021-03-23 |
David Hoenig |
judy@fullenkampins.com |
Fort Madison |
Lee |
Iowa |
Lindsey Lampe |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Hoenig |
judy@fullenkampins.com |
Board member |
Fort Madison |
Lee |
Iowa |
Lindsey Lampe |
Judy Moeller |
Signed |
332 |
2021-09-13 13:30 |
Anonymous (not verified) |
173.23.250.91 |
Cheri’s roofing |
230 palomino pkwy Des Moines Iowa 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-09-13 |
Cheryl Martinez |
cheri6876@yahoo.com |
Des Moines |
Polk |
Iowa |
Cheryl Martinez |
Cheryl martinez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chery Martinez |
cheri6876@yahoo.com |
Owner |
Des Moines |
Polk |
Iowa |
Cheryl Martinez |
Cheryl Martinez |
Signed |
444 |
2022-04-14 15:50 |
Anonymous (not verified) |
72.10.21.42 |
Babcock Services Idaho, Inc. |
8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-14 |
Carmen Clyde |
CCLYDE@BABCOCKSERVICES.COM |
KENNEWICK |
WA |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CARMEN CLYDE |
CCLYDE@BABCOCKSERVICES.COM |
Secretary |
KENNEWICK |
Benton |
Washington |
Linda McAlister |
Cesar Jimenez |
Signed |
556 |
2022-10-12 14:02 |
Anonymous (not verified) |
204.155.61.217 |
Embassy Catering, Inc |
PO Box 2805 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-09-23 |
Ron Godwin |
ronjgodwin@aol.com |
Cedar Rapids |
Linn |
Iowa |
Molly Feldman |
Sharon Naber |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Embassy Catering, Inc. |
ronjgodwin@aol.com |
president |
Cedar Rapids |
Linn |
Iowa |
Molly Feldman |
Sharon Naber |
Signed |
668 |
2023-05-12 10:14 |
Anonymous (not verified) |
94.188.205.166 |
Design Drywall Inc. |
PO Box 457 Tiffin, IA 52340 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-05-12 |
Rudy Gonzalez |
designdrywallinc19@gmail.com |
Tiffin |
Johnson |
Iowa |
Brad Bower |
Chris Hay |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rudy Gonzalez |
designdrywallinc19@gmail.com |
President |
Tiffin |
Johnson |
Iowa |
Brad Bower |
Chris Hay |
Signed |
780 |
2023-10-04 16:18 |
Anonymous (not verified) |
94.188.207.228 |
Premier Staffing Agency |
6887 Dakota drive West Desmoines Iowa 50266 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-10 |
Felistas Kimani |
mwangifelistas4@gmail.com |
West Desmoines |
Dallas |
Iowa |
Denis Waweru |
George Komu |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Felistas Kimani |
mwangifelistas4@gmail.com |
member |
West Desmoines |
Dallas |
Iowa |
Denis Waweru |
George Komu |
Signed |
987 |
2024-05-13 17:37 |
Anonymous (not verified) |
94.188.205.175 |
Barona Enterprises, LLC |
1655 Stanbridge Ave., Roseville, MN 55113 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-13 |
Stacey Pittroff-Barona |
staceybarona@aol.com |
Roseville |
Ramsey |
Minnesota |
Isabella Barona |
Robert Barona |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Stacey Pittroff-Barona |
staceybarona@aol.com |
Owner |
Roseville |
Ramsey |
Minnesota |
Isabella Barona |
Robert Barona |
Signed |
892 |
2024-02-21 16:55 |
Anonymous (not verified) |
94.188.205.167 |
NeX Level Restoration |
314 8th ST NW Cedar Rapids, IA 52405 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-21 |
Kenneth Williams |
kncwilliams@msn.com |
Cedar Rapids |
Linn |
Iowa |
Sabrina Lovell |
Tiffany Williams |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kenneth Williams |
kncwilliams@msn.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Sabrina Lovell |
Tiffany Williams |
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 |
236 |
2021-04-14 14:59 |
Anonymous (not verified) |
75.89.76.245 |
Pillar Inc |
906 W 18th St. Nevada, IA 50201 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-14 |
Jason J Burke |
jason@pillariowa.com |
Huxley |
IA |
United States |
Debbie Goetz |
John Goetz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Matt Klucas |
matt@pillariowa.com |
VP |
Fort Dodge |
IA |
United States |
Debbie Goetz |
John Goetz |
Signed |
348 |
2021-10-20 11:06 |
Anonymous (not verified) |
97.116.100.220 |
Gonzalo construction LLC |
5517 Brookdale Dr n apt 105 Brooklyn Park, mn 55443 |
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. |
2021-10-20 |
Gonzalo Roman robles |
gonzaloconstructionmn@gmail.com |
Brooklyn park |
Hennepin |
Minnesora |
Gonzalo Roman robles |
Ashley Kraft |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gonzalo Roman robles |
gonzaloconstruction@gmail.com |
Owner |
Brooklyn park |
Hennepin |
Minnesota |
Gonzalo Roman robles |
Ashley Kraft |
Signed |
460 |
2022-05-02 10:00 |
Anonymous (not verified) |
73.9.3.194 |
ERLIN AVILA INC |
1940 N GREEN LN APT 2A PALATINE IL 60074 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-02 |
ERLIN AVILA INC |
dianalcandelaria@aol.com |
PALATINE |
COOK |
IL |
DIANA CANCELARIA |
DALILA VILLEGAS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ERLIN AVILA TORREZ |
dianalcandelaria@aol.com |
PRESIDENT |
PALATINE |
Illinois |
United States |
Diana L Candelaria |
DALILA VILLEGAS |
Signed |
572 |
2022-11-17 16:43 |
Anonymous (not verified) |
204.16.59.133 |
Washland, Inc. |
4050 W Schrock Rd, Hudson, IA 50643 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-17 |
Steven Douglas Barfels |
getclean@laundryplusiowa.com |
Hudson |
Black Hawk |
Iowa |
Joel Steven Barfels |
Vicki Lorraine Barfels |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joel Steven Barfels |
joel@laundryplusiowa.com |
Corporate Secretary |
Hudson |
Black Hawk |
Iowa |
Joel Steven Barfels |
Vicki Lorraine Barfels |
Signed |
684 |
2023-06-13 08:54 |
Anonymous (not verified) |
94.188.207.223 |
Sai Ram |
123 jjj |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-01 |
Jane Do |
heather@sfmic.com |
Crystal |
Minnesota |
United States |
Jane Do |
Jane |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
jkl |
fdaf@gmail.com |
fdas |
fdas |
fads |
fad |
afde |
fads |
Signed |
796 |
2023-10-18 14:34 |
Anonymous (not verified) |
94.188.205.177 |
Yarn Tree Designs Inc |
117 Alexander Ave, Ames, IA 50010 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-18 |
Larry R Johnson |
larry@yarntree.com |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Larry R Johnson |
larry@yarntree.com |
VP |
Ames |
Story |
Iowa |
Megan Chriswisser |
Erica Lenig |
Signed |
28 |
2020-01-07 14:23 |
Anonymous (not verified) |
204.155.62.177 |
Money Handling Machines |
PO Box 34218, Omaha NE 68134-0128 |
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. |
2020-01-01 |
David Jame Grimes |
daveg@moneyhandlingmanchines.com |
Omaha |
Douglas |
Nebraska |
Michael Bowman |
Joy Nickolte |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David James Grimes |
daveg@moneyhandlingmachines.com |
President |
Omaha |
Douglas |
NE |
Michael Bowman |
Joy Nickolite |
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 |
473 |
2022-05-16 14:20 |
Anonymous (not verified) |
167.142.231.34 |
Trust Builders, LLC |
1055 Jordan Creek Parkway, Suite 200, West Des Moines, 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. |
2022-05-16 |
Christopher Dean Petersen |
chrispetersen@trustbuildersiowa.com |
Polk City |
Polk |
Iowa |
Curtis William Blake |
Joseph Duane Meints |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher Dean Petersen |
chrispetersen@trustbuildersiowa.com |
Owner |
Polk City |
Polk |
Iowa |
Curtis William Blake |
Joseph Duane Meints |
Signed |
585 |
2022-12-15 20:32 |
Anonymous (not verified) |
192.110.196.132 |
Maywood Enterprises, Inc. |
28345 Highway 52, 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. |
2022-12-15 |
Ann L Wachtel |
annw@financepro123.com |
Bellevue |
Jackson |
Iowa |
Katie Laban |
Jeffrey Laban |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ann L Wachtel |
annw@financepro123.com |
President |
Bellevue |
Jackson |
IA |
Katie Laban |
Jeffrey Laban |
Signed |
697 |
2023-06-20 21:56 |
Anonymous (not verified) |
94.188.207.230 |
Cedar Valley Flooring |
1083 150th Plainfield Ia 50666 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-20 |
michael kASPAR |
mikekaspar@hotmail.com |
plainfield |
IA |
IOWA |
RYAN PARCHER |
JOHN STEENBLOCK |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
MICHAEL d KASPAR |
mikekaspar@hotmail.com |
PRESIDENT |
plainfield |
BREMMER |
IOWA |
JOHN STEENBLOCK |
RYAN PARCHER |
Signed |
904 |
2024-02-28 06:52 |
Anonymous (not verified) |
94.188.205.167 |
Monarca General Builders LLC. |
551 Martin Rd Waterloo Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-28 |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Antonio Serrato Sánchez |
assmsaeaj@icloud.com |
President |
Waterloo |
Black Hawk |
Iowa |
Maria santos Juarez |
Adan Alvarez |
Signed |
809 |
2023-11-08 09:47 |
Anonymous (not verified) |
94.188.207.229 |
GruntWorkz Wedling and Fab, Inc. |
15519 80th Ave Blue Grass, IA 52726 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-08 |
Brandon Joseph Fox |
GruntWorkzwelding@gmail.com |
Blue Grass |
Scott |
Iowa |
Amanda Dawn Fox |
Brandon Joseph Fox |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brandon Joseph Fox |
GruntWorkzwelding@gmail.com |
Same Person |
Blue Grass |
Scott |
Iowa |
Amanda Dawn Fox |
Brandon Joseph Fox |
Signed |
41 |
2020-02-16 19:09 |
Anonymous (not verified) |
207.199.193.217 |
S J Hernandez, Inc |
19738 133rd Street Bloomfield, IA 52537 |
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. |
2020-02-16 |
Jessica Hernandez |
jessieatcjs@gmail.com |
Bloomfield |
Davis |
Iowa |
Salvador Hernandez-Perez |
Joseph Olinger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jessica Hernandez |
jessieatcjs@gmail.com |
Owner |
Bloomfield |
Davis |
Iowa |
Salvador Hernandez-Perez |
Joseph Olinger |
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 |
265 |
2021-05-22 13:33 |
Anonymous (not verified) |
75.162.162.238 |
Superior Painting and Remodeling, corp |
8415 Franklin Ave. Apt. 49 Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-22 |
Luz Maria Morales Gutierrez |
lm3673719@gmial.com |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Luz Maria Morales Gutierrez |
lm3673719@gmial.com |
Owner |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
377 |
2021-12-30 11:42 |
Anonymous (not verified) |
216.51.165.122 |
M and K Rentals Inc. |
800 Country Club Drive, Maquoketa, IA 52060 |
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. |
2021-12-17 |
Mark F Intlekofer |
kmintlekofer@yahoo.com |
Maquoketa |
Jackson |
Iowa |
Deb L Lane |
Rachelle Zeimet |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mark F Intlekofer |
kmintlekofer@yahoo.com |
President |
Maquoketa |
Jackson |
Iowa |
Deb L Lane |
Rachelle Zeimet |
Signed |
489 |
2022-06-02 13:09 |
Anonymous (not verified) |
96.31.21.223 |
Lamfers Farm Inc |
2161 Jackson Ave George IA 51237 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-23 |
Charnele Lamfers |
rclamfers@gmail.com |
George |
Lyon |
Iowa |
Shannon Monson |
Teresa Hoogendoorn |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Roger Lamfers |
rclamfers@gmail.com |
President |
George |
Lyon |
Iowa |
Shannon Monson |
Teresa Hoogendoorn |
Signed |
601 |
2023-02-16 16:08 |
Anonymous (not verified) |
94.188.207.223 |
Friday After Work LLC |
2526 Rainbow Drive, Cedar Falls, IA 50613 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-01 |
Tyler Reynolds |
tyler.cve@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Brady Huls |
Joshua Carder |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brent Dunlop |
fawconstruction.ia@gmail.com |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
Brady Huls |
Joshua Carder |
Signed |
713 |
2023-07-25 12:26 |
Anonymous (not verified) |
94.188.205.174 |
HT&T Drywall |
479 old lincoln hwy Mechanicsville Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-25 |
Tracy Spray |
tspray9@hotmail.com |
Mechanicsville |
Cedar |
Iowa |
Dillon Williams |
Leighton Raplinger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tracy Spray |
tspray9@hotmail.com |
Owner |
Mechanicsville |
Cedar |
Iowa |
Dillon Williams |
Leighton Raplinger |
Signed |
920 |
2024-03-18 15:42 |
Anonymous (not verified) |
94.188.207.223 |
Great Tree LLC |
2701 e douglas ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-18 |
Robert buell |
Greattree55@gmail.com |
Des Moines |
IA |
United States |
ryan homan |
Jamarlo fields |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert buell |
Greattree55@gmail.com |
company owner |
Des Moines |
IA |
United States |
ryan homan |
jamarlo fields |
Signed |
825 |
2023-11-22 08:02 |
Anonymous (not verified) |
94.188.207.224 |
Sabuydee Corporation |
617 Davis Ave. / Corning, IA 50841 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-22 |
Nantawan Grundman |
lakejournal@gmail.com |
Corning |
Adams |
Iowa |
Carol Penglase |
Michael Grundman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Grundman |
adamgrundman@gmail.com |
President |
Corning |
Iowa |
United States |
Carol Penglase |
Michael Grundman |
Signed |
57 |
2020-04-10 11:14 |
Anonymous (not verified) |
136.34.78.83 |
KALONA SALES BARN, INC. |
191 9TH STREET; KALONA, IA 52247 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-07 |
DEVIN MULLET |
LMULLET@KALONASALESBARN.COM |
KALONA |
WASHINGTON |
IOWA |
ALANA MULLET |
ROCHELLE MULLET |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
DEVIN MULLET |
LMULLET@KALONASALESBARN.COM |
OWNER |
KALONA |
WASHINGTON |
IOWA |
ALANA MULLET |
ROCHELLE MULLET |
Signed |
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 |
281 |
2021-06-30 10:59 |
Anonymous (not verified) |
206.72.14.249 |
TCS Fabricating, Inc |
315 Hwy 22 Keswick, IA 50136 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-06-30 |
Tom Sieren |
TCSFAB@NETINS.NET |
Keswick |
Keokuk |
Iowa |
Scott Grimm |
Amber Kephart |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tom Sieren |
TCSFAB@NETINS.NET |
Vice President |
Keswick |
IA |
United States |
Scott Grimm |
Amber Kephart |
Signed |
393 |
2022-01-26 16:35 |
Anonymous (not verified) |
216.51.137.244 |
Metal Works, Inc. |
1015 32nd Ave W, Spencer, IA 51301 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-01 |
Ben Nystrom |
ffernandez@thamsagency.com |
Spencer |
Clay |
Iowa |
Phil Ramstack |
Francia Fernandez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ben Nystrom |
ffernandez@thamsagency.com |
Owner |
Spencer |
Clay |
Iowa |
Philp Ramstack |
Francia Fernandez |
Signed |
505 |
2022-06-30 17:20 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise |
101 Ashworth Rd |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-30 |
Admir Dogic |
adoydogic@gmail.com |
Urbandale |
polk |
iowa |
Sandro Tadic |
Andy Swanson |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Sandro Tadic |
sanienterprise14@gmail.com |
Owner |
Urbandale |
polk |
iowa |
Sandro Tadic |
Andy Swanson |
Signed |
617 |
2023-03-02 18:39 |
Anonymous (not verified) |
94.188.205.167 |
Fosters woodworking and design llc |
26498 g ave, adel ia 50003 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-02 |
Nicholas Foster |
nick@fosterswooddesign.com |
Adel |
Dallas |
Iowa |
Tanya Foster |
Mike Merrick |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nicholas Foster |
nfoster1988@icloud.com |
Owner |
Adel |
Dallas |
Iowa |
Tanya foster |
Mike merrick |
Signed |
729 |
2023-08-04 07:39 |
Anonymous (not verified) |
94.188.207.228 |
Barrel Head Winery Inc |
9995 Laudeville Road, 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. |
2023-08-03 |
Aaron Fuhreck |
sales@barrelheadiowa.com |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Aaron Fuhreck |
sales@barrelheadiowa.com |
Owner |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
936 |
2024-03-30 16:41 |
Anonymous (not verified) |
94.188.205.176 |
Rhubarb Botanicals LLC |
650 Martelle Rd, Springville IA 52336 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-30 |
Emma Barber |
emma@rhubarbbotanicals.com |
Springville |
Linn |
Iowa |
Lena Wilhelm |
Harvey Wilhelm |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Emma Barber |
emma@rhubarbbotanicals.com |
Co-Owner |
Springville |
Linn |
Iowa |
Lena Wilhelm |
Harvey Wilhelm |
Signed |
841 |
2023-12-18 16:28 |
Anonymous (not verified) |
94.188.205.168 |
Dennis Clement |
203 Astor 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. |
2023-12-18 |
Dennis Clement |
haight0929@gmail.com |
Des Moines |
Polk |
IA |
Amanda Thompson |
Brandi Haight |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dennis Clement |
haight0929@gmail.com |
none |
Des Moines |
polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
73 |
2020-04-28 22:27 |
Anonymous (not verified) |
72.25.27.81 |
Clanton Creek Land Improvement |
3094 Pheasant Run Trail Peru, IA 50222 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-04-28 |
Travis James Tuttle |
t.tuttle1982@gmail.com |
Peru |
Madison |
Iowa |
Sabrina Elaine Tuttle |
Spencer Gregory Minnich |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis James tuttle |
t.tuttle1982@gmail.com |
President |
Peru |
Madison |
Iowa |
Sabrina Elaine Tuttle |
Spencer Gregory Minnich |
Signed |
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 |
297 |
2021-07-30 11:05 |
Anonymous (not verified) |
165.225.60.212 |
Love Tap Racing LLC |
1122 Sunset Ave, Kelley, IA 50134 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-30 |
Timothy Love |
tiredemon@gmail.com |
Kelley |
Story |
IA |
Katie Frame |
Cody Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Timothy Love |
tiredemon@gmail.com |
Owner |
Ames |
Story |
IA |
Katie Frame |
Cody Jones |
Signed |
409 |
2022-02-18 11:32 |
Anonymous (not verified) |
173.31.148.43 |
PACKEBUSH SPRINKLER SERVICE INC |
1960 170TH AVE MILFORD, IA 51351 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-02-09 |
KARA PACKEBUSH |
RKPACKEBUSH@GMAIL.COM |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
KARA PACKEBUSH |
JOEL@WALKERINSURANCEIA.COM |
VICE PRESIDENT |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |