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 |
596 |
2023-02-06 08:08 |
Anonymous (not verified) |
107.121.104.18 |
Household Nanny |
1357 Woolridge Dr., Coralville, IA 52241 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-02-06 |
Stephen John Statz |
sstatz32@gmail.com |
Coralville |
IA |
United States |
Jeffrey Peterson |
Casey Edwards |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Stephen John Statz |
sstatz32@gmail.com |
Owner |
Coralville |
IA |
United States |
Jeffrey Peterson |
Casey Edwards |
Signed |
597 |
2023-02-06 08:11 |
Anonymous (not verified) |
107.121.104.18 |
Household Nanny |
1357 Woolridge Dr., Coralville, IA 52241 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-02-06 |
Giselle Marie Statz |
Gisellestatz@gmail.com |
Coralville |
IA |
United States |
Jeffrey Peterson |
Casey Edwards |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Giselle Marie Statz |
gisellestatz@gmail.com |
Owner |
CORALVILLE |
Johnson |
Iowa |
Jeffrey Peterson |
Casey Edwards |
Signed |
612 |
2023-02-24 08:02 |
Anonymous (not verified) |
94.188.205.166 |
Ketter Household |
3517 Witmer Pkwy |
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. |
2023-02-24 |
Sarah Jones Ketter |
sarahajones09@gmail.com |
Des Moines |
IA |
United States |
Christopher Ketter |
Stacia Fuller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sarah Jones Ketter |
sarahajones09@gmail.com |
Same |
Des Moines |
IA |
United States |
Christopher Ketter |
Stacia Fuller |
Signed |
614 |
2023-02-28 07:24 |
Anonymous (not verified) |
94.188.207.229 |
River City Transport, Inc |
131 West 10th st, 4th floor Dubuque, IA 52001 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-02-28 |
Brian Brewer |
brian@rivercitylogistics.net |
Sparks |
NV |
United States |
Matthew Gazzola |
Jacob Shireman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brian Brewer |
brian@rivercitylogistics.net |
Vice President |
Sparks |
NV |
United States |
Matthew Gazzola |
Jacob Shireman |
Signed |
619 |
2023-03-06 09:02 |
Anonymous (not verified) |
94.188.207.229 |
Gaytan Framing LLC |
4745 NE 27th Ct Des Moines IA 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. |
2023-03-06 |
Jose Gaytan |
jose1988.jg8@gmail.com |
Des Moines |
Iowa |
United States |
Carla Gaytan |
Eduardo Vazquez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jose Gaytan |
jose1988.jg8@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Carla Gaytan |
Eduardo Vazquez |
Signed |
622 |
2023-03-08 13:40 |
Anonymous (not verified) |
94.188.207.226 |
DDD Construction |
624 west maple P.O.164 Allerton |
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. |
2023-03-08 |
Douglas Dean Downs |
tripledconstruction@hotmail.com |
ALLERTON |
IA |
United States |
June Lynette Downs |
William Lee Downs |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Douglas Dean Downs |
tripledconstruction@hotmail.com |
Coowner |
ALLERTON |
IA |
United States |
June Lynette Downs |
William Lee Downs |
Signed |
623 |
2023-03-08 13:48 |
Anonymous (not verified) |
94.188.205.174 |
Jim & Laini's Trucking Inc |
11591 Rupp Hollow 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. |
2023-03-08 |
James Harry |
jltiowa@gmail.com |
DUBUQUE |
IA |
United States |
Christopher T Clarke |
Chris Clarke |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Harry |
jltiowa@gmail.com |
owner |
DUBUQUE |
IA |
United States |
Christopher T Clarke |
Chris Clarke |
Signed |
624 |
2023-03-08 13:50 |
Anonymous (not verified) |
94.188.205.177 |
Jim & Laini's Trucking Inc |
11591 Rupp Hollow 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. |
2023-03-08 |
Elaine Harry |
jltiowa@gmail.com |
DUBUQUE |
Iowa |
United States |
Christopher T Clarke |
Chris Clarke |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Harry |
jltiowa@gmail.com |
owner |
DUBUQUE |
IA |
United States |
Christopher T Clarke |
Chris Clarke |
Signed |
628 |
2023-03-21 12:07 |
Anonymous (not verified) |
94.188.207.226 |
Deep Cleaning Janitorial Inc |
3131 33rd Ave SW Ceder 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. |
2023-03-21 |
Paul Mwai |
deepcleaning0142@gmail.com |
Cedar Rapids |
IA |
United States |
Mary Ngotho |
John Johnson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ray Robertson |
deepcleaning0142@gmail.com |
Co-Owner |
Cedar Rapids |
Linn |
United States |
John Johnson |
Mary Ngotho |
Signed |
629 |
2023-03-21 12:14 |
Anonymous (not verified) |
94.188.207.230 |
Deep Cleaning Janitorial Inc |
3131 33rd Ave SW Ceder 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. |
2023-03-21 |
Ray Robertson |
deepcleaning0142@gmail.com |
Cedar Rapids |
linn |
United States |
Shelley Robertson |
William Robertson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Mwai |
deepcleaning0142@gmail.com |
Co-Owner |
Cedar Rapids |
Linn |
IA |
Shelley Robertson |
William Robertson |
Signed |
640 |
2023-03-28 18:28 |
Anonymous (not verified) |
94.188.205.174 |
SM TILE DESIGN LLC |
670 Daybreak 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. |
2023-03-28 |
Samir Mulalic |
smtiledesign@gmail.com |
Waukee |
Iowa |
United States |
Samir Mulalic |
Saneta Dzankovic |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Samir Mulalic |
smtiledesign@gmail.com |
Owner |
Waukee |
Iowa |
United States |
Samir Mulalic |
Saneta Dzankovic |
Signed |
650 |
2023-04-10 13:06 |
Anonymous (not verified) |
94.188.205.168 |
Deep Cleaning Janitorial Inc |
3131 33rd Ave SW Ceder 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. |
2023-04-11 |
Paul Mwai |
deepcleaning0142@gmail.com |
Cedar Rapids |
IA |
United States |
Mary Ngotho |
John Johnson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ray Robertson |
deepcleaning0142@gmail.com |
Co-Owner |
Cedar Rapids |
Linn |
United States |
Shelley Robertson |
William Robertson |
Signed |
651 |
2023-04-10 13:21 |
Anonymous (not verified) |
94.188.205.175 |
Deep Cleaning Janitorial Inc |
3131 33rd Ave SW Ceder 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. |
2023-04-10 |
Ray Robertson |
deepcleaning0142@gmail.com |
Cedar Rapids |
IA |
United States |
Shelley Robertson |
William Robertson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Mwai |
deepcleaning0142@gmail.com |
Co-Owner |
Cedar Rapids |
Linn |
United States |
Mary Ngotho |
John Johnson |
Signed |
652 |
2023-04-17 16:23 |
Anonymous (not verified) |
94.188.205.177 |
alternative sport enterprises llc |
506 6th st coralville IA 52241 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-17 |
nick carroll |
nick.carroll@mchsi.com |
Coralville |
IA |
United States |
Kaylyn Olson |
Jake Braman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
nick carroll |
nick.carroll@mchsi.com |
owner |
Coralville |
IA |
United States |
Kaylyn Olson |
Jake Braman |
Signed |
657 |
2023-04-20 11:33 |
Anonymous (not verified) |
94.188.205.177 |
Debra Higgins |
201 Cedar st |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-20 |
Debra Higgins |
diggs0519@icloud.com |
Slater |
IA |
United States |
Howard Higgins |
Howard Higgins |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Debra Higgins |
diggs0519@icloud.com |
owner |
Slater |
IA |
United States |
Howard Higgins |
Howard Higgins |
Signed |
658 |
2023-04-20 11:39 |
Anonymous (not verified) |
94.188.205.167 |
Old Pros Consulting Inc |
201 Cedar St Slater Iowa 50244 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-20 |
Debra Higgins |
diggs0519@icloud.com |
Slater |
IA |
United States |
Howard Higgins |
Howard Higgins |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Debra Higgins |
diggs0519@icloud.com |
owner |
Slater |
IA |
United States |
Howard Higgins |
Howard Higgins |
Signed |
659 |
2023-04-21 13:58 |
Anonymous (not verified) |
94.188.205.168 |
Streamline Plumbing LLC |
1513 Nw 8th St Grimes, IA 50111 |
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. |
2023-04-21 |
Benjamin Molloy |
slplumbing.llc@gmail.com |
Grimes |
IA |
United States |
Christine Darnell |
Steven Perona |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Benjamin Molloy |
slplumbing.llc@gmail.com |
owner |
Grimes |
IA |
United States |
Christine Darnell |
Steven Perona |
Signed |
660 |
2023-04-26 07:56 |
Anonymous (not verified) |
94.188.207.227 |
Darrin Hearn DBA GoodCauseMinis |
445 Onyx Ave Marion IA 52302 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-26 |
Darrin Hearn |
goodcauseminis@gmail.com |
Marion |
IA |
United States |
Darrin Hearn |
Darrin Hearn |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Darrin Hearn |
goodcauseminis@gmail.com |
owner |
Marion |
IA |
United States |
Darrin Hearn |
Darrin Hearn |
Signed |
663 |
2023-05-03 12:53 |
Anonymous (not verified) |
94.188.205.177 |
Seven Oaks Recreation |
1086 222nd Dr., 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. |
2023-05-03 |
Joel Bryan |
joel@sevenoaksrec.com |
Ogden |
Boone |
United States |
Anthony Calek |
Craig Christensen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sara Bryan |
sara@sevenoaksre.com |
Director/Vice-President/Secretary |
Boone |
Boone |
United States |
Anthony Calek |
Craig Christensen |
Signed |
680 |
2023-06-06 16:43 |
Anonymous (not verified) |
94.188.205.167 |
Great Tree LLC |
2701 e douglas ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-06 |
Timothy william Buell |
tbuell52@gmail.com |
Des Moines |
IA |
United States |
tyler smith |
Jamarlo fields |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert buell |
Greattree55@gmail.com |
company owner |
Des Moines |
IA |
United States |
jamarlo fields |
tyler Smith |
Signed |
684 |
2023-06-13 08:54 |
Anonymous (not verified) |
94.188.207.223 |
Sai Ram |
123 jjj |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-01 |
Jane Do |
heather@sfmic.com |
Crystal |
Minnesota |
United States |
Jane Do |
Jane |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
jkl |
fdaf@gmail.com |
fdas |
fdas |
fads |
fad |
afde |
fads |
Signed |
692 |
2023-06-19 08:00 |
Anonymous (not verified) |
94.188.207.224 |
Mr chipper llc |
1606 carrie 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. |
2023-06-19 |
Nicholas Earles |
mrchipper2020@gmail.com |
Des Moines |
Iowa |
United States |
Nicholas belger |
Melanie earles |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nicholas Earles |
mrchipper2020@gmail.com |
Owner |
Des Moines |
Iowa |
United States |
Nicholas belger |
Melanie earles |
Signed |
693 |
2023-06-19 15:48 |
Anonymous (not verified) |
94.188.207.224 |
mike mcfarland |
7212 parkwood ln ne |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-19 |
michael chad mcfarland |
mikecmcfarland@gmail.com |
cedar rapids |
linn |
United States |
Omar M Zepeda |
jamie mcfarland |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
michael chad mcfarland |
mikecmcfarland@gmail.com |
myself |
cedar rapids |
linn |
United States |
Omar M Zepeda |
jamie mcfarland |
Signed |
699 |
2023-06-21 14:04 |
Anonymous (not verified) |
94.188.205.166 |
WRS Inc |
5225 NE 17th St. Des Moines, 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. |
2023-06-21 |
Kevin A Alderman |
alderman@wrsia.com |
Urbandale |
Iowa |
United States |
John Kaldenberg |
Ronda Perry |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kevin Alderman |
alderman@wrsia.com |
President / Owner |
Urbandale |
Iowa |
United States |
John Kaldenberg |
Ronda Perry |
Signed |
708 |
2023-07-14 09:24 |
Anonymous (not verified) |
94.188.205.166 |
Ellis Flying Service Inc. |
6550 HWY 17 South Newport AR 72112 |
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. |
2023-07-14 |
Mark Ellis |
fly@ellisflying.com |
Newport |
Arkansas |
United States |
Alex Webb |
Becky Ellis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mark A Ellis |
fly@ellisflying.com |
President |
Newport |
Arkansas |
United States |
Alex Webb |
Becky Ellis |
Signed |
712 |
2023-07-24 12:34 |
Anonymous (not verified) |
94.188.205.168 |
BOG Roofing |
3768 Deerbrook 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. |
2023-07-24 |
Devon Booton |
devonboot1973@gmail.com |
Bettendorf |
Iowa |
United States |
Viviana Gonzalez |
Shannon Wolever |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Devon Booton |
devonboot1973@gmail.com |
Self |
Bettendorf |
Iowa |
United States |
Viviana Gonzalez |
Shannon Wolever |
Signed |
714 |
2023-07-25 16:16 |
Anonymous (not verified) |
94.188.207.224 |
Midwest Systems |
2877 130th St Aurora, Ia 50607 |
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 |
Matt Griswold |
midwestsystems@live.com |
Aurora |
IA |
United States |
Creatleigh Griswold |
Carslyn Griswold |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Matt Griswold |
midwestsystems@live.com |
Owner |
Aurora |
IA |
United States |
Creatleigh Griswold |
Carslyn Griswold |
Signed |
722 |
2023-08-01 11:55 |
Anonymous (not verified) |
94.188.207.229 |
SM TILE DESIGN LLC |
670 Daybreak 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. |
2023-08-01 |
Samir Mulalic |
smtiledesign@gmail.com |
Waukee |
Iowa |
United States |
Samir Mulalic |
Saneta Dzankovic |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Samir Mulalic |
smtiledesign@gmail.com |
Owner |
Waukee |
Iowa |
United States |
Samir Mulalic |
Saneta Dzankovic |
Signed |
723 |
2023-08-01 15:37 |
Anonymous (not verified) |
94.188.205.169 |
Flow Media, Inc |
1710 Wenig Rd NE |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-01 |
Courtney Tabelisma Ball |
courtney@flowmedia.com |
Cedar Rapids |
IA |
United States |
Hannah Jane White |
Gregory Michael White |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Courtney Tabelisma Ball |
courtney@flowmedia.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Sonya Catherine Geenen |
Gregory Michael White |
Signed |
728 |
2023-08-03 12:28 |
Anonymous (not verified) |
94.188.205.166 |
Advanced Plumbing LLC |
2538 Carbide Ln, 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. |
2023-08-03 |
James O'Shea |
advancedplumbing1@yahoo.com |
Keokuk |
Iowa |
United States |
Rebecca O'Shea |
Tate O'Shea |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James O'Shea |
advancedplumbing1@yahoo.com |
Partner |
Keokuk |
Iowa |
United States |
Rebecca O'Shea |
Tate O'Shea |
Signed |
740 |
2023-08-14 10:25 |
Anonymous (not verified) |
94.188.205.167 |
Absolute Mud Jacking Inc |
5038 Brittany Ct 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. |
2023-08-12 |
Paul Pelzer |
pelzer830@gmail.com |
Bettendorf |
IA |
United States |
Brett Lewandowski |
Phil Schaefer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Pelzer |
pelzer830@gmail.com |
Owner |
Bettendorf |
IA |
United States |
Brett Lewandowski |
Phil Schaefer |
Signed |
754 |
2023-08-21 17:14 |
Anonymous (not verified) |
94.188.205.177 |
Burgess Investments DBA Heartland Pest Control Inc |
PO Box 8043 Cedar Rapids, IA 52408 |
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. |
2023-08-21 |
CURT BURGESS |
curtburgess73@gmail.com |
CEDAR RAPIDS |
IA |
United States |
Doug Wilson |
Michael McMeins |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CURT BURGESS |
curtburgess73@gmail.com |
Self |
CEDAR RAPIDS |
IA |
United States |
Doug Wilson |
Michael McMeins |
Signed |
756 |
2023-08-28 09:10 |
Anonymous (not verified) |
94.188.205.177 |
J.R. Stelzer Co. |
5850 Russell Dr Ste 1, Lincoln, NE 68507 |
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. |
2023-07-01 |
William James Stelzer |
bill@jrstelzer.com |
Lincoln |
Nebraska |
United States |
Michael G Stelzer |
Marcia Brouillette |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William James Stelzer |
bill@jrstelzer.com |
Officer |
Lincoln |
Lancaster |
NE |
Michael G. Stelzer |
Marcia Brouillette |
Signed |
757 |
2023-08-28 12:11 |
Anonymous (not verified) |
94.188.207.230 |
J.R. Stelzer Co |
5850 Russell Dr. Lincoln, NE 68507 |
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 |
Mike Stelzer |
mike@jrstelzer.com |
Lincoln |
NE |
United States |
Bill Stelzer |
Jim Stelzer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mike Stelzer |
mike@jrstelzer.com |
President |
Lincoln |
Lancaster |
NE |
Bill Stelzer |
Jim Stelzer |
Signed |
770 |
2023-09-14 16:23 |
Anonymous (not verified) |
94.188.205.167 |
Volt Electric Inc |
24 Thompson 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. |
2023-09-14 |
Lucas Beschta |
voltelectriciowa@gmail.com |
Palo |
IA |
United States |
Sage Stulz |
Kolt Stulz-obrien |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Full Name BRIAN C. EDDY |
BEddy@robertseddy.com |
Lawyer for the company |
Independace |
buchanan |
IA |
sage stulz |
Kolt stulz-obrien |
Signed |
772 |
2023-09-18 12:52 |
Anonymous (not verified) |
94.188.207.224 |
Wallenburg Trucking LLC |
911 8th Street 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. |
(1) I reject the employers’ liability coverage. |
2023-09-18 |
Heath Ryan Wallenburg |
heathwallenburg@gmail.com |
Rock Valley |
IA |
United States |
Dustin Van Beek |
Lucas Van Engen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Deric Hill |
d.hill@joemorten.com |
Insurance |
Sioux City NE |
Dakota County |
Nebraska |
Dustin Van Beek |
Lucas Van Engen |
Signed |
776 |
2023-10-02 07:19 |
Anonymous (not verified) |
94.188.205.176 |
Silver Fox Construction |
1238 71st |
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. |
2023-10-02 |
Scott Klinkefus |
scott.klinkefus@gmail.com |
Windsor Heights |
Iowa |
United States |
Kristin Brantley |
Matt Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott Klinkefus |
scott.klinkefus@gmail.com |
Same |
Windsor Heights |
Iowa |
United States |
Kristin Brantley |
Matt Jones |
Signed |
786 |
2023-10-16 07:27 |
Anonymous (not verified) |
94.188.207.230 |
Aurora Aesthetics and Functional Medicine LLC |
713 1st Ave 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. |
2023-10-04 |
Meagan Mclaughlin |
meagan.vitae@gmail.com |
Mount Vernon |
IA |
United States |
Michael Friess |
Stephanie Friess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Friess |
Aurorafunctionalmed@gmail.com |
business manager |
Mt Vernon |
IA |
United States |
Stephanie Friess |
Meagan Friess |
Signed |
787 |
2023-10-16 07:30 |
Anonymous (not verified) |
94.188.207.223 |
Aurora Aesthetics and Functional Medicine LLC |
713 1st Ave 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. |
2023-10-04 |
Meagan Mclaughlin |
Aurorafunctionalmed@gmail.com |
Mount Vernon |
IA |
United States |
Stephanie Friess |
Michael Friess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Friess |
Aurorafunctionalmed@gmail.com |
business manager |
Mount Vernon |
Iowa |
United States |
Meagan Mclaughlin |
Stephanie Friess |
Signed |
788 |
2023-10-16 07:32 |
Anonymous (not verified) |
94.188.207.225 |
Aurora Aesthetics and Functional Medicine LLC |
713 1st Ave 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. |
2023-10-04 |
Stephanie Friess |
Aurorafunctionalmed@gmail.com |
Mount Vernon |
IA |
United States |
Michael Friess |
Meagan Friess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Friess |
mfriess1985@gmail.com |
business manager |
Mount Vernon |
Iowa |
IA |
Michael Friess |
Meagan Friess |
Signed |
789 |
2023-10-16 07:38 |
Anonymous (not verified) |
94.188.205.177 |
Aurora Aesthetics and Functional Medicine LLC |
713 1st Ave 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. |
2023-10-04 |
Michael Friess |
Aurorafunctionalmed@gmail.com |
Mount Vernon |
IA |
United States |
Meagan Mclaughlin |
Stephanie Friess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Stephanie Friess |
Aurorafunctionalmed@gmail.com |
Owner |
Mount Vernon |
Iowa |
United States |
Michael Friess |
Meagan Mclaughlin |
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 |
793 |
2023-10-18 08:18 |
Anonymous (not verified) |
94.188.205.168 |
J&M Tire and Repair |
31006 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. |
2023-10-18 |
Jacob Mills Barkley |
jmtireandrepair@gmail.com |
sioux city |
Iowa |
United States |
Alex Barkley |
Victoria Barkley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jacob Mills Barkley |
jmtireandrepair@gmail.com |
Owner |
sioux city |
Iowa |
United States |
Alex Barkley |
Victoria Barkley |
Signed |
794 |
2023-10-18 08:21 |
Anonymous (not verified) |
94.188.205.177 |
J&M Tire and Repair |
31006 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. |
2023-10-18 |
Macklin Paul Barkley |
flyingtank92@yahoo.com |
merrill |
Iowa |
United States |
Brandon Norris |
Alex Barkley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Macklin Paul Barkley |
jmtireandrepair@gmail.com |
Owner |
sioux city |
Iowa |
United States |
Brandon Norris |
Alex Barkley |
Signed |
808 |
2023-11-08 07:37 |
Anonymous (not verified) |
94.188.207.229 |
Cush Comfort |
1225 e. River Dr STE 206 Davenport IA 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. |
2023-10-30 |
Chris Cushman |
ccushman82@gmail.com |
Milan |
IL |
United States |
Deena Maurus |
Jenna Ortberg |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher Cushman |
ccushman82@gmail.com |
Owner |
Milan |
IL |
United States |
Deena Maurus |
Jenna Ortberg |
Signed |
815 |
2023-11-14 13:42 |
Anonymous (not verified) |
94.188.207.224 |
SunsetSue, LLC |
240 Solomia Court, Peosta, IA 52068 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-14 |
Lori Sue Stewart |
lori@hrbcplus.com |
Peosta |
IA |
United States |
Mark R Stewart |
Danielle M Leibfried |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lori S Stewart |
lori@hrbcplus.com |
Self |
Peosta |
IA |
United States |
Mark R Stewart |
Danielle M. Leibfried |
Signed |
824 |
2023-11-21 13:22 |
Anonymous (not verified) |
94.188.207.227 |
OhZone. LLC |
852 Washington Street Burlington, IA 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. |
2023-11-19 |
Jeffery W Ishmael |
jeffishmael@gmail.com |
Des Moines |
IA |
United States |
Juan DeLlanos |
Gregory Gunter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffery W Ishmael |
jeffishmael@gmail.com |
Co-Owner |
Des Moines |
IA |
United States |
Juan DeLlanos |
Gregory Gunter |
Signed |
829 |
2023-11-27 08:59 |
Anonymous (not verified) |
94.188.207.224 |
Adam Ruess Masonry |
206.w Elm st |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-27 |
Adam Ruess |
ruess33@gmail.com |
Lone Tree |
IA |
United States |
Adam Ruess |
Adam Ruess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Ruess |
ruess33@gmail.com |
Owner |
Lone Tree |
IA |
United States |
Adam Ruess |
Adam Ruess |
Signed |