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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:
621 2023-03-08 07:53 Anonymous (not verified) 94.188.207.223 Don Wyckoff Heating Inc. 95 Highway 5, Carlisle, IA 50047 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-04 Michael T Johnson mikeyjay1968@gmail.com Des Moines Polk IA Brady Cooper Carey Cooper Signed (1) The corporation rejects the employers’ liability coverage. Mike Johnson mikeyjay@gmail.com Sub-Contractor Des Moines Polk IA Brady Cooper Carey Cooper Signed
353 2021-11-04 11:41 Anonymous (not verified) 108.58.173.242 ASTL Moving And Storage Inc 9530 FM 2920 #227 Tomball TX 77375 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. 2021-11-04 Peter Allen III astlmoving@yahoo.com Tomball Harris TX Peggi Makofka Yoel Taran Signed (1) The corporation rejects the employers’ liability coverage. Peter Allen III astlmoving@yahoo.com owner Tomball Harris TX Peggi Makofka Yoel Taran Signed
939 2024-04-01 11:44 Anonymous (not verified) 94.188.207.228 SFA INC 955 31ST MARION, IA 52302-3788 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. 2024-04-01 SARAH FERRETER sarah@sfacpa.com MARION LINN IOWA WILLIE CALDWELL ALEXANDRA BACHMAN Signed (1) The corporation rejects the employers’ liability coverage. WILLIE CALDWELL WILLIE.CALDWELL.B2SH@STATEFARM.COM AGENT CEDAR RAPIDS LINN IOWA WILLIE CALDWELL ALEXANDRA BACHMAN 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
273 2021-06-08 12:34 Anonymous (not verified) 40.135.3.146 Gordinier Construction Inc 9555 SE 6th Ave, Runnells IA 50237 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-06 Dustin Gordinier gordinierconstruction@gmail.com Runnells Polk IA Robert Simmons Joe Meyers Signed (1) The corporation rejects the employers’ liability coverage. Dustin Gordinier gordinierconstruction@gmail.com Self Runnells Polk IA Robert Simmons Joe Meyers Signed
268 2021-05-25 10:03 Anonymous (not verified) 174.198.97.100 Paradigm Construction, LLC 960 Pelican Dr I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-25 Joshua Beougher jbooyah84@gmail.com Winterset Madison Iowa Ryan Shabino Jonathon Curtis Signed (1) The corporation rejects the employers’ liability coverage. Ryan Shabino ryan@prdgmconstruction.com Owner Polk City Polk Iowa Josh Beougher Jonathon Curtis Signed
638 2023-03-25 13:19 Anonymous (not verified) 94.188.207.227 Paradigm Group LLC 960 Pelican Drive I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-13 Dalton Vest vestdalton@gmail.com State Center Marshal Iowa Andie Phillips Kade Steuhm Signed (1) The corporation rejects the employers’ liability coverage. Ryan Shabino ryan@prdgmgroup.com Owner Polk City Polk Iowa Andie Phillips Kade Steuhm Signed
400 2022-02-04 10:37 Anonymous (not verified) 173.16.199.106 Paradigm Construction 960 Pelican Drive – Polk City, IA 50226 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-04 MATTHEW HENDRICKSON matthendrickson88@gmail.com NORWALK IA United States Richard Green Sheldon Thompson Signed (1) The corporation rejects the employers’ liability coverage. Ryan Shabino ryan@prdgmconstruction.com Contractor 960 Pelican Drive – Polk City, IA 50226 Polk Iowa Richard Green Sheldon Thompson Signed
493 2022-06-08 13:00 Anonymous (not verified) 173.31.148.43 OKOBOJI PERFORMING ARTS 97 WOODLIN DR 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. 2022-06-06 JESSICA SCHABLE JESS@OKOBOJIPERFORMINGARTS.COM MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. JESSICA SCHABLE JESS@OKOBOJIPERFORMINGARTS.COM SELF MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
494 2022-06-08 13:04 Anonymous (not verified) 173.31.148.43 OKOBOJI PERFORMING ARTS 97 WOODLIN DR 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. 2022-06-08 JOHN MOORE JOHN@OKOBOJIPERFORMINGARTS.COM MINNEAPOLIS HENNEPIN MN JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. JOHN MOORE JOHN@OKOBOJIPERFORMINGARTS.COM SELF MINNEAPOLIS HENNEPIN MN JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
495 2022-06-08 13:07 Anonymous (not verified) 173.31.148.43 OKOBOJI PERFORMING ARTS 97 WOODLIN DR 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. 2022-06-08 DREW DUNCAN DREW@OKOBOJIPERFORMINGARTS.COM LINCOLN LANCASTER NE JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. DREW DUNCAN DREW@OKOBOJIPERFORMINGARTS.COM SELF LINCOLN LANCASTER NE JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
844 2023-12-29 08:28 Anonymous (not verified) 94.188.207.226 Emcubed Enterprises, Inc 979 40th Ave, Bettendorf, IA 52722 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. 2023-12-29 Bradley David Morrison brad@riverbendsignworks.com Moline Rock Island IL David Rodriguez Lisbet Lule Signed (1) The corporation rejects the employers’ liability coverage. Bradley David Morrison brad@riverbendsignworks.com Owner Moline Rock Island IL David Rodriguez Lisbet Lule Signed
862 2024-01-22 13:55 Anonymous (not verified) 94.188.207.228 Emcubed Enterprises, Inc 979 40th Ave, Bettendorf, IA 52722 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. 2024-01-22 Bradley D Morrison brad@riverbendsignworks.com Moline Rock Island IL Richard Henning Kyle Sebben Signed (1) The corporation rejects the employers’ liability coverage. Brad Morrison brad@riverbendsignworks.com Owner Moline Rock Island IL Richard Henning Kyle Sebben 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
877 2024-01-30 17:58 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 Steffanie Mortens steffanie.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
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
730 2023-08-04 07:42 Anonymous (not verified) 94.188.207.225 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 Jodie Fuhreck sales@barrelheadiowa.com Dubuque Dubuque Iowa Derrick Parsons Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Jodie Fuhreck sales@barrelheadiowa.com Owner Dubuque Dubuque Iowa Derrick Parsons Derrick Parsons Signed
343 2021-10-07 15:12 Anonymous (not verified) 73.191.238.89 Kleaveland Brothers, Inc. c/o 5724 36th Avenue NE, Seattle, WA 98105 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. 2021-10-07 Michael I. Kleaveland kleaveland@comcast.net Muskegon Muskegon MI Amanda A. Finch Enrika L.F. McGahan Signed (1) The corporation rejects the employers’ liability coverage. Michael I. Kleaveland kleaveland@comcast.net Secretary/Treasurer Muskegon Muskegon MI Amanda A. Finch Enrika L.F. McGahan Signed
344 2021-10-07 15:22 Anonymous (not verified) 73.191.238.89 Kleaveland Brothers, Inc c/o 5724 36th Avenue, Ne. Seattle, WA 98105 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. 2021-10-07 I. Justin Kleaveland justinqt@comcast.net North Muskegon Muskegon MI Amanda A. Finch Enrika L.F. McGahan Signed (1) The corporation rejects the employers’ liability coverage. I. Justin Kleaveland justinqt@comcast.net Vice President North Muskegon Muskegon MI Amanda A. Finch Enrika L.F. McGahan Signed
765 2023-09-12 12:44 Anonymous (not verified) 94.188.207.229 Southwest Sanitation Inc Clarinda, 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. 2023-09-12 Lindsay A Schrock swsanitation@gmail.com Bedford Taylor Iowa Robin Wilmarth Bryan Wilmarth Signed (1) The corporation rejects the employers’ liability coverage. Lindsay Schrock swsanitation@gmail.com Treasure Bedford Taylor Iowa Robin Wilmarth Bryan Wilmarth Signed
766 2023-09-12 12:46 Anonymous (not verified) 94.188.207.224 Southwest Sanitation Clarinda, 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. 2023-09-12 Craig Schrock swsanitation@gmail.com Bedford Taylor Iowa Robin Wilmarth Bryan Wilmarth Signed (1) The corporation rejects the employers’ liability coverage. Lindsay Schrock swsanitation@gmail.com Treasure Bedford Taylor Iowa Robin Wilmarth Bryan Wilmarth Signed
767 2023-09-12 12:48 Anonymous (not verified) 94.188.207.223 Southwest Sanitation Clarinda, 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. 2023-09-12 Lonnie Weed swsanitation@gmail.com Bedford Taylor Iowa Robin Wilmarth Bryan Wilmarth Signed (1) The corporation rejects the employers’ liability coverage. Lindsay Schrock swsanitation@gmail.com Treasure Bedford Taylor Iowa Robin Wilmarth Bryan Wilmarth Signed
769 2023-09-12 12:49 Anonymous (not verified) 94.188.207.223 Southwest Sanitation Clarinda, 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. 2023-09-12 Joshua Weed swsanitation@gmail.com Bedford Taylor Iowa Robin Wilmarth Bryan Wilmarth Signed (1) The corporation rejects the employers’ liability coverage. Lindsay Schrock swsanitation@gmail.com Treasure Bedford Taylor Iowa Robin Wilmarth Bryan Wilmarth Signed
450 2022-04-20 13:42 Anonymous (not verified) 96.85.81.137 D&K Harvesting Inc. P.o Box 1347 LaBelle Fl 33975 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. 2022-04-20 James Larry Marsh Jr larrym3041@aol.com Fort myers Lee Florida Anita Coronado Christy Pequeno Signed (2) The corporation declines to reject the employers’ liability coverage. James Larry Marsh Jr larrym3041@aol.com Owner Fort myers Lee Florida Anita Coronado Christy Puequeno Signed
148 2020-12-30 08:22 Anonymous (not verified) 166.181.83.201 Elite Carpentry P.O. Box 1162 Bettendorf Iowa 52722 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. 2020-12-30 Jeffrey D Leech Elitecarpentryqc@gmail.com Bettendorf Scott Iowa Jeremy Havens Michael Rodriguez Signed (1) The corporation rejects the employers’ liability coverage. Jeffrey D Leech Elitecarpentryqc@gmail.com Owner Bettendorf Scott Iowa Jeremy Havens Michael Rodriguez Signed
396 2022-02-01 10:03 Anonymous (not verified) 184.80.177.137 LKB Holdings, LLC P.O. box 313 - Monona, Ia 52159 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. 2022-01-29 Kandi Gillitzer jheims@english-insurance.com Monoa Clayton Iowa Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com self Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
118 2020-09-15 14:32 Anonymous (not verified) 174.243.115.133 Jurisdiction Approved Plumbing Corporation P.O. Box 343 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-15 Christian m Lavia eeejumble@gmail.com Urbandale Polk Iowa Tina m Heuckendorf Roslyn Heuckendorf Signed (1) The corporation rejects the employers’ liability coverage. Christian m Lavia eeejumble@gmail.com Director Urbandale Polk IOWA Tina m Heuckendorf Roslyn Heukendorf Signed
279 2021-06-23 10:41 Anonymous (not verified) 184.80.177.137 AA Breeders P.O. Box 470 - Epworth, IA 52045 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-22 Justin Curtis jheims@english-insurance.com Epworth Dubuque Iowa Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. AA Breeders - Justin Curtis jheims@english-insurance.com self Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
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
34 2020-01-16 13:10 Anonymous (not verified) 108.171.132.188 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 Caleb Elliott onethird4599@gmail.com Boone Boone Iowa Katie Frame Jessica Carroll Signed (1) The corporation rejects the employers’ liability coverage. Caleb Elliott onethird4599@gmail.com Owner Boone Boone IOWA Katie Frame Jessica Carroll Signed
447 2022-04-15 16:59 Anonymous (not verified) 166.181.87.86 STEVE MORRISON TRUCKING P.O. Box 66 Danville,IA 52623 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. 2022-04-15 Stephen D. Morrison sdmt13@gmail.com Danville Des Moines IA Ellie Miller Janice Helt Signed (1) The corporation rejects the employers’ liability coverage. Stephen Dwight Morrison sdmt13@gmail.com Owner Danville Des Moines IA Ellie Miller Janice Helt 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
142 2020-12-02 09:39 Anonymous (not verified) 208.90.15.53 Humboldt Community Daycare, Inc. DBA Kiddie Cats Childcare and Learning Center P.O. Box 93 Dakota City, Ia 50529 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-02 Angelique Berry dcity@goldfieldaccess.net Algona Kossuth Iowa Ross Sleiter Scott Curran Signed (1) The corporation rejects the employers’ liability coverage. Angelique Berry dcity@goldfieldaccess.net Secretary/Treasurer Algona Kossuth Iowa Ross Sleiter Scott Curran Signed
143 2020-12-02 09:43 Anonymous (not verified) 208.90.15.53 Humboldt Community Daycare, Inc. DBA Kiddie Cats Childcare and Learning Center P.O. Box 93 Dakota City, Ia 50529 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-02 Rob Dickey robd@fsbwc.com Gilmore City Humboldt Iowa Ross Sleiter Scott Curran Signed (1) The corporation rejects the employers’ liability coverage. Rob Dickey robd@fwbwc.com Vice President Gilmore City Humboldt Iowa Ross Sleiter Scott Curran Signed
807 2023-11-07 11:25 Anonymous (not verified) 94.188.205.167 Keokuk Termite & Pest Control, INC. P.O.Box 422 Keokuk, IA 52632 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-07 Marc Lee Floyd keokuktermite@gmail.com Keokuk Lee Iowa Kayla Joanne Tonkin Esther Mae Floyd Signed (1) The corporation rejects the employers’ liability coverage. Marc Lee Floyd keokuktermite@gmail.com Owner Keokuk Lee Iowa Kayla Joanne Tonkin Esther Mae Floyd Signed
114 2020-09-04 13:11 Anonymous (not verified) 107.182.207.0 KEITH N SLYTER PO 2632 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-04 KEITH N SLYTER KNSCONST@GMAIL.COM DAVENPORT 25|IA iowa KEITH N SLYTER KEITH N SLYTER Signed (1) The corporation rejects the employers’ liability coverage. KEITH N SLYTER KNSCONST@GMAIL.COM owner DAVENPORT 25|IA iowa KEITH N SLYTER KEITH N SLYTER Signed
48 2020-03-18 09:58 Anonymous (not verified) 67.22.192.111 Rozeboom Trucking Inc. PO Box 110 Sioux Center IA 51250 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. 2020-03-18 Kirk Hulstein kirkh@barkcattle.com Sioux Center Sioux Iowa Linda Kieft Tiffany Govig Signed (1) The corporation rejects the employers’ liability coverage. Kirk Hulstein kirkh@barkcattle.com president Sioux Center Sioux Iowa Linda Kieft Tiffany Govig Signed
49 2020-03-18 10:03 Anonymous (not verified) 67.22.192.111 Rozeboom Trucking Inc. PO Box 110 Sioux Center IA 51250 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. 2020-03-18 Kelly Hulstein kellyh@barkcattle.com Sioux Center Sioux Iowa Linda Kieft Tiffany Govig Signed (1) The corporation rejects the employers’ liability coverage. Kirk Hulstein kirkh@barkcattle.com president Sioux Center Sioux Iowa Linda Kieft Tiffany Govig Signed
50 2020-03-18 10:06 Anonymous (not verified) 67.22.192.111 Rozeboom Trucking Inc. PO Box 110 Sioux Center IA 51250 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. 2020-03-18 Kraig Hulstein kraigh@barkcattle.com Sioux Center Sioux Iowa Linda Kieft Tiffany Govig Signed (1) The corporation rejects the employers’ liability coverage. Kirk Hulstein kirkh@barkcattle.com president Sioux Center Sioux Iowa Linda Kieft Tiffany Govig Signed
229 2021-04-05 13:44 Anonymous (not verified) 173.18.193.51 Denmark Sanitary District PO Box 141, Denmark, Iowa 52624 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. 2021-04-03 Clay Fullenkamp judy@fullenkampins.com West Point Lee Iowa Judy Moeller Brian Stuekerjuergen Signed (2) The corporation declines to reject the employers’ liability coverage. Clay Fullenkamp judy@fullenkampins.com Board Member West Point Lee Iowa judy moeller brian stuekerjuergen Signed
839 2023-12-18 16:12 Anonymous (not verified) 94.188.207.227 515 Painting llc po box 157 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 Marvin S Parker JR stvpkr@gmail.com berwick polk iowa Christopher Eldridge Dillon Parker Signed (1) The corporation rejects the employers’ liability coverage. Marvin parker stvpkr@gmail.com owner berwick Polk Iowa Christopher Eldridge Dillon Parker Signed
864 2024-01-23 14:31 Anonymous (not verified) 94.188.207.230 Firm Foundation Concrete PO Box 164 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. 2024-01-23 Greg Schut firmfoundationbros@gmail.com Sioux Center Sioux Iowa Erica Schut Miguel Perez Signed (1) The corporation rejects the employers’ liability coverage. Greg Schut firmfoundationbros@gmail.com Owner Sioux Center Sioux IA Erica Schut Miguel Perez Signed
866 2024-01-23 14:40 Anonymous (not verified) 94.188.207.225 Firm Foundation Concrete PO Box 164 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. 2024-01-23 Lyle Schut firmfoundationbros@gmail.com Sioux Center Sioux Iowa Erica Schut Miguel Perez Signed (1) The corporation rejects the employers’ liability coverage. Lyle Schut firmfoundationbros@gmail.com Owner Sioux Center Sioux IA Erica Schut Miguel Perez Signed
425 2022-03-16 07:57 Anonymous (not verified) 173.29.149.199 Schult Industries Inc PO Box 165 Camanche, IA 52730 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. 2022-03-17 MIKE SCHULT mschult10@gmail.com CLINTON Clinton Iowa Rhonda Schult Lance VanDeest Signed (1) The corporation rejects the employers’ liability coverage. MIKE SCHULT mschult10@gmail.com Owner CLINTON Clinton Iowa Rhonda Schult Lance VanDeest Signed
215 2021-03-29 07:58 Anonymous (not verified) 173.18.193.51 Lee County Fair, Inc PO Box 179 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. 2021-03-05 Dillon Benner judy@fullenkampins.com ARgyle IA United States Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Dillon Benner judy@fullenkampins.com Board Member Argyle IA United States Lindsey Lampe Judy Moeller Signed
216 2021-03-29 08:01 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. 2021-03-03 Bryan Bredemeyer judy@fullenkampins.com Bonaparte IA United States Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Brian Bredemeyer judy@fullenkampins.com Board Member Bonaparte IA United States Lindsey Lampe Judy Moeller Signed
217 2021-03-29 08:03 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 Erin Wagnoer judy@fullenkampins.com Donnellson Lee Iowa Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Erin Wagner judy@fullenkampins.com Board Member donnellson Lee Iowa Lindsey Lampe Judy Moeller Signed
218 2021-03-29 08:04 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. 2021-03-03 Matthew Wilson judy@fullenkampins.com Donnellson Lee Iowa Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Matthew Wilson judy@fullenkampins.com Board Member Donnellson Lee Iowa l0 Judy Moeller Signed
219 2021-03-29 08:05 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. 2021-03-03 Brock Westfall judy@fullenkampins.com Montrose Lee Iowa Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Brock Westfall judy@fullenkampins.com Board Member Montrose Lee Iowa Lindsey Lampe Judy Moeller 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