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Rejection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Corporation: Address of Corporation Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Statement Agreement: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Agreement: Alternative Selection: Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Corporation of Authorized Agent: City of Residence: County of Residence: State: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
266 2021-05-22 13:38 Anonymous (not verified) 75.162.162.238 Superior Painting and Remodeling, corp 8415 Franklin Ave. Apt. 49 Clive, Iowa 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-22 Elmer Lopez Montufar lm3673719@gmial.com Des Moines USA Iowa Yolanda Mendoza Liliana Sanchez Signed (2) The corporation declines to reject the employers’ liability coverage. Superior Painting and Remodeling Corp lm3673719@gmial.com Owner Des Moines USA Iowa Yolanda Mendoza Liliana Sanchez Signed
284 2021-06-30 14:27 Anonymous (not verified) 75.162.212.130 Superior Painting and Remodeling, corp 8415 Franklin Ave Apt 49 Clive, Iowa 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-30 Elmer Lopes Montufar lm3673719@gmail.com Des Moines United State Iowa Liliana Sanchez Yolanda Mendoza Signed (2) The corporation declines to reject the employers’ liability coverage. Superior Painting and Remodeling Corp lm3673719@gmail.com Owner Des Moines United State Iowa Liliana Sanchez Yolanda Mendoza Signed
285 2021-06-30 14:33 Anonymous (not verified) 75.162.212.130 Superior Painting and Remodeling, corp 8415 Franklin Ave Apt 49 Clive, Iowa 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-30 Luz Maria Morales Gutierrez lm3673719@gmail.com Des Moines United State Iowa Liliana Sanchez Yolanda Mendoza Signed (2) The corporation declines to reject the employers’ liability coverage. Superior Painting and Remodeling Corp lm3673719@gmail.com Owner Des Moines United State Iowa Liliana Sanchez Yolanda Mendoza Signed
149 2020-12-31 14:59 Anonymous (not verified) 216.81.153.249 S&A Holdings LLC 115 N 2nd Street, Fort Dodge, IA 50501 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. 2020-12-21 Surinder Kumar NONE@GMAIL.COM Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed (1) The corporation rejects the employers’ liability coverage. Surinder Kumar NONE@GMAIL.COM Owner Storm Lake Buena Vista IA Jared Brashears Mary Jo Olthoff Signed
867 2024-01-24 15:04 Anonymous (not verified) 94.188.207.227 Shook Handyman 2415 Plum Creek 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. 2024-01-24 Nolan Shook office@shookhandyman.com Sioux City Woodbury IA McKenna Warner Jessica Shook Signed (1) The corporation rejects the employers’ liability coverage. Susan Geist sgeist@paychex.com Paychex Insurance Agency Inc Rochester Monroe NY Nolan Shook McKenna Warner Signed
850 2024-01-11 15:22 Anonymous (not verified) 94.188.205.167 CUB CONSTRUCTION LLC 4243 GRANDVIEW AVE, DES MOINES, IOWA 50317 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-11 SUSANA MELENDEZ melendezsusana342@gmail.com Des Moines Polk Iowa Elsa Villanueva Jaime Leiva Signed (1) The corporation rejects the employers’ liability coverage. Susana Melendez melendezsusana342@gmail.com Owner Des Moines Pok Iowa Elsa Villanueva Jaime Leiva 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
598 2023-02-10 09:38 Anonymous (not verified) 94.188.207.225 Y & M Cleaning Services Inc. 4380 SE 15th 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. 2023-02-10 Martine Martinez martinmtzmartinez@gmail.com Des Moines Polk Iowa Suzanne E Collier Andy Boyd Signed (1) The corporation rejects the employers’ liability coverage. Suzanne E Collier scollie1@amfam.com Non Related Altoona Polk IA Andy Boyd Martin Martinez Signed
274 2021-06-14 08:34 Anonymous (not verified) 207.191.207.6 Total Health Rehabilitation PC 4332 Pioneer Tr SE, Cedar Rapids, IA 52403 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-14 Suzanne E. Cooper tcc@acterragroup.net Cedar Rapids Linn Iowa Tad C Cooper Hallie S Cooper Signed (1) The corporation rejects the employers’ liability coverage. Suzanne E. Cooper tcc@acterragroup.net President Cedar Rapids Linn Iowa Tad C Cooper Hallie S Cooper Signed
63 2020-04-20 13:23 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Suzie Wilmot jennifer@walkerinsuranceia.com Minneapolis Hennepin Minnesota Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Suzie Wilmot jennifer@walkerinsuranceia.com Board Member Minneapolis Hennepin Minnesota Joseph Thomas Loring Jennifer Janet Youngwirth Signed
47 2020-03-10 15:16 Anonymous (not verified) 65.126.161.162 Advantage Customer Remodeling LLC 3236 W 17th Street 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. 2020-03-10 Tamethia Mitchell None@none.com Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed (1) The corporation rejects the employers’ liability coverage. Tamethia Mitchell None@none.com Owner Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed
806 2023-11-06 13:52 Anonymous (not verified) 94.188.205.168 Southeast Iowa behavioral Healthcare center 101 north 12th keokuk 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. 2023-11-06 Kendall elder klelder48@gmail.com Keokuk Lee Iowa Kendall elder Darian Miller Signed (1) The corporation rejects the employers’ liability coverage. Tami elder telder@leximgtoncg.com Payroll Keokuk Lee Iowa Kendall elder Darian miller Signed
983 2024-05-11 12:27 Anonymous (not verified) 94.188.207.225 Aluminum King MFG LTD 700 E Van Buren St, Mitchell, IA 50461 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. 2024-05-11 Jeremy Mostek katie@flashingthunder.com Mitchell Mitchell IA Kristy Wolfe Tami Towne Signed (1) The corporation rejects the employers’ liability coverage. Tami Towne ttowne@ryderinsurance.com Agent Grand Island Hall NE Kristy Wolfe Katherine Mostek Signed
223 2021-03-29 08:11 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. 2021-03-04 Tammy LeMaster judy@fullenkampins.com Argyle Lee iowa Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Tammy LeMaster judy@fullenkampins.com Board Member ARgyle Lee Iowa Lindsey Lampe Judy Moeller Signed
748 2023-08-20 14:18 Anonymous (not verified) 94.188.205.177 NexLevelMoving 1186 capital dr sw 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. 2023-08-16 Ethan Daniel Sailer ethan.sailer@hscsi.net Cedar Rapids Linn County Iowa Denis Sailer Penny Sailer Signed (2) The corporation declines to reject the employers’ liability coverage. Tarin Erenberger tarin.nexlevelmoving@gmail.com Employee Cedar Rapids Linn County Iowa Taj Barrett Taj Barrett Signed
813 2023-11-14 13:00 Anonymous (not verified) 94.188.207.226 NeX Level Moving, LLC 5634 Deerwood St. SW, Cedar Rapids, IA, 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-14 Garrett Allen Reno garrettreno2001@gmail.com Tipton Cedar Iowa Bridget Camp Tarin Erenberger Signed (1) The corporation rejects the employers’ liability coverage. Tarin Erenberger tarin.nexlevelusa@gmail.com Operations Director Cedar Rapids Linn Iowa Bridget Camp Garrett Reno Signed
553 2022-10-03 15:32 Anonymous (not verified) 165.206.254.105 Ski Mechanical Services 729 Bell Ave. Des Moines, IA 50315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-03 Terry Wave Konchalski skiwave79@gmail.com Des Moines Polk Iowa Melissa Kerr Charlie Ruperto Signed (1) The corporation rejects the employers’ liability coverage. Terry Wave Konchalski skiwave79@gmail.com Owner/President Des Moines Polk Iowa Melissa Kerr Charlie Ruperto Signed
351 2021-10-25 08:24 Anonymous (not verified) 208.95.64.3 Ron Sexton Construction Inc, 1184 Vine Ave, Riverside IA 52327 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. 2021-09-27 Theresa A Sexton ashmac@iowatelecom.net Riverside Washington IA Greg Martin Michele McMichael Signed (1) The corporation rejects the employers’ liability coverage. Theresa A Sexton ashmac@iowatelecom.net VP, Secretary, Treasurer Riverside Washington IA Greg Martin Michele McMichael Signed
368 2021-11-24 07:11 Anonymous (not verified) 173.20.97.32 Neppl Landscape Architecture and Planning, LLC 3013 Briggs Circle Ames, Iowa 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. 2021-11-24 Thomas George Neppl tom@tomneppl.com Ames Story Iowa Ashlyn Kay Neppl Tricia Kay Neppl Signed (1) The corporation rejects the employers’ liability coverage. Thomas George Neppl tom@tomneppl.com Owner Ames Story Iowa Ashlyn Kay Neppl Tricia Kay Neppl Signed
768 2023-09-12 12:48 Anonymous (not verified) 94.188.207.224 BSSI MW 23959 580th 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. 2023-08-28 Tom Barragy tom@agvolution.co Ames Boone Iowa Blaine Bancks Pete Romig Signed (1) The corporation rejects the employers’ liability coverage. Thomas j Barragy tbarragy@agvolution.co ownet AMES Boone ia Blaine Bancks Pete Romig Signed
480 2022-05-30 11:37 Anonymous (not verified) 134.215.6.237 Access Property Management Corp DBA Wine & Spirits 510 E Carrington Ln, Appleton, WI 54913 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. 2022-05-30 Lisa M Ricklefs lisarick19@yahoo.com Appleton Outagamie WI Jeff Fonferek Melissa Fonferek Signed (1) The corporation rejects the employers’ liability coverage. Thomas Ricklefs tjrick@yahoo.com President Appleton Outagamie WI Jeff Fonferek Melissa Fonferak Signed
195 2021-03-02 16:29 Anonymous (not verified) 173.29.156.163 Certified drywall 329 e.11th st Davenport, Iowa 52803 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-02 Thomas wells mikeparry783@gmail.com Davenport Scott Iowa Chyna rose pena Natalie parry Signed (2) The corporation declines to reject the employers’ liability coverage. Thomas wells mikeparry783@gmail.com Self Davenport Scott Iowa Chyna rose pena Natalie parry Signed
323 2021-08-30 12:22 Anonymous (not verified) 173.19.179.111 OKOBOJI TREE SPECIALISTS II iNC PO BOX 515 MILFORD, IA 51351 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-13 THOMAS WRIGHT joel@walkerinsuranceia.com MILFORD DICKINSON IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. THOMAS WRIGHT joel@walkerinsuranceia.com ADMIN ST PAUL MN 55106 JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
595 2023-01-31 09:35 Anonymous (not verified) 50.83.168.191 Lumos Electric, Inc DBA Dave Bessine Electric 705 Valley Street, Burlington, Iowa, 52601 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-01-31 Shawna Brown recdbessine@qwestoffice.net Burlington iowa United States Shelly Knight DeeAnn Howard Signed (1) The corporation rejects the employers’ liability coverage. Tim Brown recdbessine@qwestoffice.net Vice-President Burlington iowa United States Shelly Knight DeeAnn Howard 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
272 2021-06-08 12:32 Anonymous (not verified) 40.135.3.146 Gordinier Construction Inc 9555 SE 6th Ave, Runnells IA 50237 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-06 Tim Gordinier gordinierconstruction@gmail.com Runnnells POLK IA Robert Simmons Joe Meyers Signed (1) The corporation rejects the employers’ liability coverage. Tim Gordinier gordinierconstruction@gmail.com Self Runnells Polk IA Robert Simmons Joe Meyers Signed
945 2024-04-03 20:00 Anonymous (not verified) 94.188.207.229 Timberview Construction 803 TIMBERVIEW DR I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-03 Parker Evans Pcevans28@gmail.com ADEL IA United States jason Evans Tricia Evans Signed (1) The corporation rejects the employers’ liability coverage. Timberview Construction Pcevans28@gmail.com Myself ADEL IA United States Jason Evans Tricia Evans Signed
907 2024-03-01 12:13 Anonymous (not verified) 94.188.207.230 Bulls Eye Builders Llc 406 E South st 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. 2024-03-01 Timothy Hansel bullseyebuildersllc@gmail.com Mechanicsville Cedar Iowa Kevin Kofron Jackie hart Signed (1) The corporation rejects the employers’ liability coverage. Timothy Hansel bullseyebuildersllc@gmail.com Owner Mechanicsville Iowa United States Kevin Kofron Jackie Hart 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
361 2021-11-15 18:08 Anonymous (not verified) 199.66.15.123 Wills Work 302 N Kenwood Blvd 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. 2021-11-15 Timothy Williams Robinson williamswork18@gmail.com Indianola Warren Iowa Andrew Gilbert Barber Sarah Anne Robinson Signed (1) The corporation rejects the employers’ liability coverage. Timothy Will Robinson williamswork18@gmail.com CEO Indianola Warren Iowa Andrew Gilbert Barber Sarah Anne Robinson Signed
402 2022-02-09 09:46 Anonymous (not verified) 69.57.33.202 Toby K's Hideaway Inc. dba Toby K's Hideaway 1723 Mamie Eisenhower Ave, Boone IA 50036 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 Toby Kruse samanthapeck@boehmins.com Boone Boone Iowa Samantha Peck Hans Boehm Signed (1) The corporation rejects the employers’ liability coverage. Toby Kruse samanthapeck@boehmins.com Owner Boone Boone Iowa Samantha Peck Hans Boehm 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
605 2023-02-17 11:29 Anonymous (not verified) 94.188.207.223 McDonald Construction 617 Kingsley Ave, 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. 2022-02-17 Todd Gelner toddandabbey@yahoo.com Denver Bremer Iowa Abbey Gelner Abbey Elizabeth-Anne Gelner Signed (1) The corporation rejects the employers’ liability coverage. Todd Gelner toddandabbey@yahoo.com Self Denver Bremer Iowa Abbey Gelner Karen Henry Signed
145 2020-12-18 07:54 Anonymous (not verified) 173.215.16.15 Dohrmann Enterprises Inc 2652 350th Ave DeWitt, IA 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. 2020-12-18 Tom Dohrmann dohrmannpnh@gmail.com DeWitt Clinton Iowa Susanne Owen Daron Oberbroeckling Signed (1) The corporation rejects the employers’ liability coverage. Tom Dohrmann dohrmannpnh@gmail.com Owner DeWitt Clinton Iowa Susanne Owen Daron Oberbroeckling Signed
271 2021-06-01 15:39 Anonymous (not verified) 206.72.14.249 TCS Fabricating, Inc 315 Hwy 22 Keswick, IA 50136 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-21 Tom Sieren TCSFAB@NETINS.NET Keswick Keokuk Iowa Scott Grimm Amber Kephart Signed (1) The corporation rejects the employers’ liability coverage. Tom Sieren TCSFAB@NETINS.NET Vice President Keswick Keokuk Iowa Scott Grimm Amber Kephart Signed
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
308 2021-08-13 15:23 Anonymous (not verified) 65.154.100.34 World of Reptiles Inc dba Snakes Alive 3901 NW Seasons Ct Ankeny, IA 50023 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-09 Tom Weidner mmatlock@thedanaco.com Des Moines Polk IA Megan Matlock Ron Goodman Signed (1) The corporation rejects the employers’ liability coverage. Tom Weidner mmatlock@thedanaco.com Owner Des Moines Polk IA Megan Matlock Ron Goodman Signed
374 2021-12-17 08:19 Anonymous (not verified) 69.63.16.2 AT Construction Inc. 5 Westview Acres NE, Iowa City IA 52240 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 Tomas Acas atconstruction@hotmail.com Iowa City Johnson Iowa Steve Fishman Dyan Kriener Signed (1) The corporation rejects the employers’ liability coverage. Tomas Acas atconstruction@hotmail.com President Iowa City Johnson Iowa Steve Fishman Dyan Kriener Signed
197 2021-03-03 11:16 Anonymous (not verified) 173.31.147.225 TLI INVESTMENTS INC 1712 368TH AVE ESTHERVILLE, IA 51334 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-15 TRACE IVERSON JOEL@WALKERINSURANCE.COM ESTHERVILLE EMMET IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. TRACE IVERSON TBYRDLES@YAHOO.COM VICE PRESIDENT ESTHERVILLE EMMET IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
371 2021-12-09 11:03 Anonymous (not verified) 216.81.176.153 Concentric International Inc. 1901 Bell Ave Ste 18, Des Moines, IA 50315-1067 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. 2021-12-09 Tracey Ball tball@ruan.com Urbandale IA United States Jackie Walker Craig Gesme Signed (1) The corporation rejects the employers’ liability coverage. Tracey Ball tball@ruan.com Treasurer Urbandale IA United States Jackie Walker Craig Gesme Signed
340 2021-10-01 15:44 Anonymous (not verified) 3.217.29.203 Tracy Countryman 745 Robert Drive Moville, IA 51039 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. 2021-09-30 Tracy Countryman Tracycountryman@ymail.com Moville Woodbury Iowa Deborah Clark Jane Ashley Signed (1) The corporation rejects the employers’ liability coverage. Tracy Countryman Tracycountryman@ymail.com President Moville Woodbury Iowa Deborah Clark Jane Ashley 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
718 2023-07-27 08:43 Anonymous (not verified) 94.188.207.225 HT&T Drywall 479 Old Lincoln Hwy 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. 2023-07-27 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
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
852 2024-01-14 15:48 Anonymous (not verified) 94.188.205.166 B St. Construction + Design, Inc. 16 Southwest 42nd 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. 2024-01-14 Travis D Crouch trvscrouch@gmail.com Des Moines Iowa United States Jodi Essex Linda K Renze Signed (1) The corporation rejects the employers’ liability coverage. Travis D Crouch trvscrouch@gmail.com President Des Moines IA United States Jodi Essex Linda K Renze Signed
32 2020-01-14 10:33 Anonymous (not verified) 108.171.132.189 B & C Lawn Care Inc P.O. Box 55, Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-01-01 Travis Garrett onethird4599@gmail.com Boone Boone Iowa Katie Frame Jessica Carroll Signed (1) The corporation rejects the employers’ liability coverage. Travis Garrett onethird4599@gmail.com Owner Boone Boone IOWA Katie Frame Jessica Carroll 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
791 2023-10-17 16:21 Anonymous (not verified) 94.188.207.229 HEIMGARTNER INSURANCE INC 26511 Hedge 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. 2023-10-17 Travis Heimgarter travis.insure@gmail.com Merrill ia United States Malinda Short Scott Delperdang Signed (1) The corporation rejects the employers’ liability coverage. Travis Heimgarter travis.insure@gmail.com President Merrill ia United States Malinda Short Scott Delperdang Signed
792 2023-10-17 16:23 Anonymous (not verified) 94.188.207.226 HEIMGARTNER INSURANCE INC 26511 Hedge 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. 2023-10-17 Gina Heimgartner travis.insure@gmail.com Merrill ia United States Malinda Short Scott Delperdang Signed (1) The corporation rejects the employers’ liability coverage. Travis Heimgartner travis.insure@gmail.com President Sioux City Iowa United States Malinda Short Scott Delperdang 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