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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:
903 2024-02-27 13:54 Anonymous (not verified) 94.188.205.166 MELTZ'S CONSTRUCTION LLC 402 Jennifer Ln NE Cedar Rapids IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-27 RICARDO MELTZ waymakeranasolorzano@gmail.com CADAR RAPIDS IA United States Lysandra Betancourt Belkis S Diaz Signed (1) The corporation rejects the employers’ liability coverage. ALAN SALGADO alan@prime-agents.com OWNER IRVING TX United States Lysandra Betancourt Belkis S Diaz Signed
64 2020-04-20 13:30 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Mike Bennett jennifer@walkerinsuranceia.com Jefferson Union South Dakota Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Mike Bennett jennifer@walkerinsuranceia.com Treasurer Jefferson Union South Dakota Joseph Thomas Loring Jennifer Janet Youngwirth Signed
743 2023-08-15 15:03 Anonymous (not verified) 94.188.205.177 R & T Trucking LLC 1374 Creamery Road, Afton Iowa 50830 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. 2023-08-15 Robert Dike robandteenadike@outlook.com Afton Union Iowa Kristina Dike Robert Dike Signed (1) The corporation rejects the employers’ liability coverage. Robert Dike robandteenadike@outlook.com Owner Afton Union Iowa Kristina Dike Robert Dike Signed
283 2021-06-30 14:24 Anonymous (not verified) 75.162.212.130 Superior Painting and Remodeling, corp 8415 Franklin Ave Apt 49 Clive, Iowa 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-30 Luz Maria Morales Gutierrez lm3673719@gmail.com Des Moines United State Iowa Liliana Sanchez Yolanda Mendoza Signed (2) The corporation declines to reject the employers’ liability coverage. Luz Maria Morales Gutierrez lm3673719@gmail.com Owner Des Moines United State Iowa Liliana Sanchez Yolanda Mendoza Signed
284 2021-06-30 14:27 Anonymous (not verified) 75.162.212.130 Superior Painting and Remodeling, corp 8415 Franklin Ave Apt 49 Clive, Iowa 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-30 Elmer Lopes Montufar lm3673719@gmail.com Des Moines United State Iowa Liliana Sanchez Yolanda Mendoza Signed (2) The corporation declines to reject the employers’ liability coverage. Superior Painting and Remodeling Corp lm3673719@gmail.com Owner Des Moines United State Iowa Liliana Sanchez Yolanda Mendoza Signed
285 2021-06-30 14:33 Anonymous (not verified) 75.162.212.130 Superior Painting and Remodeling, corp 8415 Franklin Ave Apt 49 Clive, Iowa 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-30 Luz Maria Morales Gutierrez lm3673719@gmail.com Des Moines United State Iowa Liliana Sanchez Yolanda Mendoza Signed (2) The corporation declines to reject the employers’ liability coverage. Superior Painting and Remodeling Corp lm3673719@gmail.com Owner Des Moines United State Iowa Liliana Sanchez Yolanda Mendoza Signed
990 2024-05-15 23:19 Anonymous (not verified) 94.188.205.177 The Olam LLC 2821 S 36th Omaha Nebraska 68105 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-15 Carlos Sanchez Sjuan944@gmail.com Omaha United State Nebraska Juan Sanchez Gaspar Sanchez Signed (1) The corporation rejects the employers’ liability coverage. Carlos Sanchez theolam587@gmail.com Owner Omaha United State Nebraska Juan Sanchez Gaspar Sanchez Signed
610 2023-02-23 16:19 Anonymous (not verified) 94.188.207.228 Glorious tile service llc 3905 NE 6th st Ankeny IA 50021 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. 2023-02-23 Heileselaisi unguec glorioustile6@gmail.com Ankeny United States IOWA Robert duku Abraham deng Signed (2) The corporation declines to reject the employers’ liability coverage. Heileselaisi unguec glorioustile6@gmail.com Owner llc member Ankeny United States Iowa Robert duku Abraham deng Signed
611 2023-02-23 16:27 Anonymous (not verified) 94.188.207.224 Sandra unguec 3905 NE 6th st Ankeny IA 50021 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. 2023-02-23 Sandra unguec glorioustile6@gmail.com Ankeny United States Iowa Robert duku Abraham deng Signed (2) The corporation declines to reject the employers’ liability coverage. Sandra unguec glorioustile6@gmail.com Wife of the owner Ankeny United States Iowa Robert duku Abraham deng Signed
821 2023-11-17 13:30 Anonymous (not verified) 94.188.207.230 ABC LOCK INC. 2209 2nd Ave S. P.O. Box 433 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. 2023-11-17 Dennis Diekhuis keyman@cltel.net Clear Lake United States Iowa Dennis Diekhuis Dennis Diekhuis Signed (1) The corporation rejects the employers’ liability coverage. Dennis Diekhuis keyman@cltel.net Owner Clear lake United States Iowa Dennis Diekhuis Dennis Diekhuis Signed
208 2021-03-16 16:19 Anonymous (not verified) 204.155.61.217 AGSPIRE INC 1310 Kathryn Ct Buffalo, MN 55313 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-02 Kent Kiebelkorn kent@hailmayday.com Buffalo Wright County Minnesota Docusign Docusign Signed (2) The corporation declines to reject the employers’ liability coverage. unknown akraft@millerhartwig.com Unknown unknown unknown unknown unknown unknown Signed
782 2023-10-05 09:40 Anonymous (not verified) 94.188.207.226 Haes Floorcovering 2282 290th st. New London, Ia 52645 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. 2023-10-05 John Haes floorman.0742@yahoo.com New London US Iowa Miranda Haes Tom Haes Signed (1) The corporation rejects the employers’ liability coverage. John Haes floorman.0742@yaoo.com Owner New London US Iowa Miranda Haes Tome Haes Signed
805 2023-10-31 14:53 Anonymous (not verified) 94.188.207.225 PJ Trucking Unlimited LLC 2617 380th 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. 2023-10-31 Peggy Jensen pegandhalj@gmail.com Farragut Fremont Iowa Julie Marshall Darlene Carpenter Signed (1) The corporation rejects the employers’ liability coverage. Peggy Jensen pegandhalj@gmail.com Member Farragut US US Julie Marshall Darlene Carpenter Signed
265 2021-05-22 13:33 Anonymous (not verified) 75.162.162.238 Superior Painting and Remodeling, corp 8415 Franklin Ave. Apt. 49 Clive, Iowa 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-22 Luz Maria Morales Gutierrez lm3673719@gmial.com Des Moines USA Iowa Yolanda Mendoza Liliana Sanchez Signed (2) The corporation declines to reject the employers’ liability coverage. Luz Maria Morales Gutierrez lm3673719@gmial.com Owner Des Moines USA Iowa Yolanda Mendoza Liliana Sanchez Signed
266 2021-05-22 13:38 Anonymous (not verified) 75.162.162.238 Superior Painting and Remodeling, corp 8415 Franklin Ave. Apt. 49 Clive, Iowa 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-22 Elmer Lopez Montufar lm3673719@gmial.com Des Moines USA Iowa Yolanda Mendoza Liliana Sanchez Signed (2) The corporation declines to reject the employers’ liability coverage. Superior Painting and Remodeling Corp lm3673719@gmial.com Owner Des Moines USA Iowa Yolanda Mendoza Liliana Sanchez Signed
800 2023-10-23 07:40 Anonymous (not verified) 94.188.207.228 Lucas construction inc 1707 mondamin ave des moines , 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. 2023-10-23 Luis Arturo Martinez Lucas luiss_95@icloud.com Des Moines USA Iowa Cristian António Martínez Lucas Manuel canizales Signed (1) The corporation rejects the employers’ liability coverage. Luis Arturo Martinez Lucas luiss_95@icloud.com President Des Moines Usa Iowa Cristian António Martínez Lucas Manuel canizales Signed
40 2020-02-14 09:22 Anonymous (not verified) 50.83.38.221 Pa's Construction LLC 2350 Glass 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. 2020-02-14 Daniel Saunders dan2112411@yahoo.com Cedar Rapids USA_IA USA_IA Walt Cheney Becky Cheney Signed (1) The corporation rejects the employers’ liability coverage. Daniel Saunders dan2112411@yahoo.com Owner- Manager Cedar Rapids USA_IA USA_IA Walt Cheney Becky Cheney Signed
823 2023-11-20 14:04 Anonymous (not verified) 94.188.205.169 CDNE, Inc. 311 E. Alta Vistta 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. 2023-11-20 Craig Allen Payne Craig.Payne@indianhills.edu Ottumwa Wapello Iowa Erin Elizabeth Payne Nathan Thomas Payne Signed (1) The corporation rejects the employers’ liability coverage. Desirae Lynn Payne desip845@gmail.com Spouse Ottumwa Wapello Iowa Erin Elizabeth Payne Nathan Thomas Payne Signed
44 2020-03-09 10:51 Anonymous (not verified) 184.63.116.185 STURCO BUILDERS 24472 15TH AVE NEW VIRGINIA IA 50210 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. 2020-03-09 LANE WILLIAM STURTZ Sturcobuilders@live.com New virginia warren Iowa EMILY LAURA STURTZ JODI LEEANN GARNER Signed (1) The corporation rejects the employers’ liability coverage. LANE WILLIAM STURTZ Sturcobuilders@live.com OWNER NEW VIRGINIA WARREN IOWA EMILY LAURA STURTZ JODI LEEANN GARNER Signed
113 2020-09-03 14:22 Anonymous (not verified) 72.255.74.171 James Raymond and Associates Inc 240 S 1st St, Carlisle, IA 50047 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-09-03 Jim Downs jdowns@arrowisg.com Carlisle Warren Iowa TJ Cataldo Patti Isley Signed (1) The corporation rejects the employers’ liability coverage. Jim Downs jdowns@arrowisg.com Owner Carlisle Warren Iowa TJ Cataldo Patti Isley Signed
162 2021-01-19 15:21 Anonymous (not verified) 72.255.74.171 JD Enterprises Inc 4807 160th Ave, 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. 2021-01-19 Jim Downs jdowns@arrowisg.com Carlisle Warren Iowa Tyler Cataldo Patti Isley Signed (1) The corporation rejects the employers’ liability coverage. Jim Downs jdowns@arrowisg.com Owner Carlisle Warren Iowa Tyler Cataldo Patti Isley Signed
319 2021-08-24 10:19 Anonymous (not verified) 174.243.114.142 Sabbatical Services LLC 20732 Johnson St., Milo, IA 50166 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-08-24 Bryce Gilbert bryce.ssllc@outlook.com Milo Warren Iowa Kathryn Gilbert Kolton Gilbert Signed (1) The corporation rejects the employers’ liability coverage. Bryce Gilbert bryce.ssllc@outlook.com President Milo Warren Iowa Kathryn Gilbert Kolton Gilbert Signed
352 2021-10-27 12:59 Anonymous (not verified) 206.80.128.65 Employee Fringes Audit Co 710 N Buxton St, Indianola, IA 50125 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. 2021-10-27 Patrick Heller patjh@yahoo.com Indianola Warren IOWA Joseph McCollum Heather Husman Signed (1) The corporation rejects the employers’ liability coverage. Judith Heller patjh@yahoo.com Owner Indianola Warren Iowa Joseph McCollum Heather Husman Signed
361 2021-11-15 18:08 Anonymous (not verified) 199.66.15.123 Wills Work 302 N Kenwood Blvd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-11-15 Timothy Williams Robinson williamswork18@gmail.com Indianola Warren Iowa Andrew Gilbert Barber Sarah Anne Robinson Signed (1) The corporation rejects the employers’ liability coverage. Timothy Will Robinson williamswork18@gmail.com CEO Indianola Warren Iowa Andrew Gilbert Barber Sarah Anne Robinson Signed
390 2022-01-20 11:06 Anonymous (not verified) 162.246.237.102 High Pointe Construction 903 Summerset pl Indianola iowa 50125 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. 2022-01-19 Andrey Shabak shabakandre@gmail.com indianola warren Iowa Inna zayets bob Signed (1) The corporation rejects the employers’ liability coverage. Andrey shabak shabakandre@gmail.com owner indianola warren ia inna zayets bob Signed
417 2022-03-03 13:20 Anonymous (not verified) 67.41.107.230 Trility Group Holdings, Inc. 14001 University Ave, Suite 300, Clive, IA 50125 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. 2022-03-03 Brenton David Rothchild brenton@trility.io Indianola Warren IA Devin Boyer Kyle Woiwood Signed (1) The corporation rejects the employers’ liability coverage. Brenton David Rothchild brenton@trility.io Treasurer Indianola Warren IA Devon Boyer Kyle Woiwood Signed
422 2022-03-08 08:56 Anonymous (not verified) 98.16.51.166 Trility Group Holdings, Inc. 14001 University Avenue, Suite 300, Clive IA 50125 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. 2022-03-08 Matthew D Edwards matthew@trility.io New Virginia Warren Iowa Devin Boyer Kyle Woiwood Signed (1) The corporation rejects the employers’ liability coverage. Matthew D Edwards matthew@trility.io President New Virginia Warren Iowa Devin Boyer Kyle Woiwood Signed
465 2022-05-08 19:08 Anonymous (not verified) 173.27.224.202 Vail Foundations 1508 West Clinton Ave Indianola, Iowa 50125 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-08 Cory Vail vailfoundations@gmail.com Indianola Warren Iowa Monica Vaik James Vail Signed (1) The corporation rejects the employers’ liability coverage. Cory James Vail vailfoundations@gmail.com President Indianola Warren Iowa Monica Vail James Vail Signed
518 2022-07-21 10:58 Anonymous (not verified) 75.162.31.164 Bengard Roofing LLC 1927 Wethersfield Dr, Norwalk, IA 50211 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. 2022-07-21 Brandon Bengard bj@bengardroofing.com Norwalk Warren IA Rebecca Bengard Juhl Bengard Signed (1) The corporation rejects the employers’ liability coverage. Brandon Bengard bj@bengardroofing.com Owner Norwalk Warren IA Becky Bengard Juhl Bengard Signed
566 2022-11-14 17:50 Anonymous (not verified) 107.77.206.66 JGR Carpentry 1305 N 6th St Apt. 11 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-14 Josiah Grant Robinson grantyboy87@yahoo.com Indianola Warren Iowa Timothy William Robinson Austin Micheal Ross Signed (1) The corporation rejects the employers’ liability coverage. Josiah Grant Robinson grantyboy87@yahoo.com Corporation President Indianola Warren Iowa Timothy William Robinson Austin Micheal Ross Signed
567 2022-11-14 18:21 Anonymous (not verified) 166.181.83.71 Beasts Bussiness 1305 N 6th St Apt. 6 Indianola, IA 50125 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-14 Jonathan Brice Robinson Beastsbeekeeping@gmail.com Indianola Warren Iowa Timothy Williams Robinson Josiah Grant Robinson Signed (1) The corporation rejects the employers’ liability coverage. Jonathan Brice Robinson Beastsbeekeeping@gmail.com Owner Indianola Warren Iowa Timothy Williams Robinson Josiah Grant Robinson Signed
721 2023-08-01 09:24 Anonymous (not verified) 94.188.205.167 Dryseal Roofing and Construction 390 Olive St Martensdale, IA 50160 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 Travis Tibbits travistibbits@yahoo.com Martensdale Warren IA Hannah Marie Tibbits Chad David Walker Signed (1) The corporation rejects the employers’ liability coverage. Dawn Marie Tibbits Tibbits6@gmail.com Spouse Martensdale Warren IA Hannah Marie Tibbits Chad David Walker Signed
733 2023-08-09 10:22 Anonymous (not verified) 94.188.207.230 Atcher Service LLC 145 Fremont Street, Hartford, IA 50118 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. 2023-08-08 Daniel J Love atcherservicetowing@gmail.com Hartford Warren Iowa Mandy Love Michael Love Signed (1) The corporation rejects the employers’ liability coverage. Mandy Love dlovem2002@gmail.com owner Hartford Warren Iowa Dan Love Michael Love Signed
734 2023-08-09 10:33 Anonymous (not verified) 94.188.207.227 Atcher Service LLC 145 Fremont Street, Hartford, IA 50118 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. 2023-08-08 Mandalena K Love dlovem2002@gmail.com Hartford Warren Iowa Dan Love Michael Love Signed (1) The corporation rejects the employers’ liability coverage. Daniel J Love atcherservicetowing@gmail.com owner Hartford Warren Iowa Dan Love Michael Love Signed
755 2023-08-25 11:34 Anonymous (not verified) 94.188.205.169 Paralax Corporation dba Beck Electric 8646 103rd Ave Indianola Iowa 50125 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. 2023-08-25 Jonathan Beck jon@beck-electric.com Indianola Warren Iowa Stephanie Watkins-Beck Michael Beck Signed (1) The corporation rejects the employers’ liability coverage. Jonathan Beck jon@beck-electric.com Owner Indianola Warren Iowa Stephanie Watkins-Beck Michael Beck Signed
764 2023-09-10 19:18 Anonymous (not verified) 94.188.205.177 Heartland Ultrasonography Group 1015 Woodland Drive Carlisle, Iowa 50047 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-09-10 Bradley C Curtis blc735@msn.com Carlisle Warren Iowa Dane Joseph Wright Michael Lee Guffey Signed (1) The corporation rejects the employers’ liability coverage. Bradley C Curtis Heartlandusgroup@outlook.com Co-owner llc Carlisle Warren Iowa Dane Joseph Wright Michael Lee Guffey Signed
830 2023-12-03 18:42 Anonymous (not verified) 94.188.205.167 Custom Decks, LLC 5719 Washington Ave, Des Moines, IA 50310-1072 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. 2023-12-03 Charles Dean Oakley IV oakleyoutdoorsolutions@gmail.com Carlisle Warren Iowa Sharon Marie Bracelin Casey John Eaton Signed (1) The corporation rejects the employers’ liability coverage. Charles Dean Oakley IV Oakleyoutdoorsolutions@gmail.com Owner Carlisle Warren Iowa Casey John Eaton Sharon Marie Bracelin Signed
887 2024-02-08 13:40 Anonymous (not verified) 94.188.207.228 Paradigm Construction 3263 Cumming Rd. Cumming, IA 50061 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-08 Justin Huss jmanhuss@gmail.com Grimes Polk Iowa Katie Hennessey Ryan Shabino Signed (1) The corporation rejects the employers’ liability coverage. Ryan Shabino office@prdgmgroup.com Owner Cumming Warren Iowa Katie Hennessey Nicole Shabino Signed
985 2024-05-13 17:15 Anonymous (not verified) 94.188.207.225 Rail and Road Equipment Co 1797 G50 HWY. St. Charles, IA. 50240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-13 Jeffrey Pontier railandroad@myomnotel.com St Charles Warren IA Abbi Goering Travis Allen Signed (1) The corporation rejects the employers’ liability coverage. Jeffrey Pontier railandroad@myomnitel.com President St Charles Warren IA Abbi Goering Travis Allen Signed
986 2024-05-13 17:26 Anonymous (not verified) 94.188.207.229 Rail and Road Equipment Co 1797 G50 HWY. St. Charles, IA. 50240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-13 Ranae Pontier railandroad@myomnitel.com St Charles Warren IA Abbi Goering Travis Allen Signed (1) The corporation rejects the employers’ liability coverage. Ranae Pontier railandroad@myomnitel.com Vice President St Charles Warren IA Abbi Goering Travis Allen Signed
993 2024-05-17 13:05 Anonymous (not verified) 94.188.205.176 Anacleto Campos Rojas 7 North Street Hartford, Iowa 50118 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-17 Anacleto Campos Rojas anacletocampos1@icloud.com Hartford Warren Iowa Benjamin Campos Rojas Ezequiel Campos Rojas Signed (1) The corporation rejects the employers’ liability coverage. Anacleto Campos Rojas anacletocampos1@icloud.com Owner Hartford Warren Iowa Benjamin Campos Rojas Ezequiel Campos Rojas Signed
56 2020-04-10 11:12 Anonymous (not verified) 136.34.78.83 KALONA SALES BARN, INC. 121 9TH ST; KALONA, IA 52247 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-06 LAVAUGHN MULLET LMULLET@KALONASALESBARN.COM KALONA WASHINGTON IOWA ALANA MULLET ROCHELLE MULLET Signed (1) The corporation rejects the employers’ liability coverage. LAVAUGHN MULLET LMULLET@KALONASALESBARN.COM OWNER KALONA WASHINGTON IOWA ALANA MULLET ROCHELLE MULLET Signed
57 2020-04-10 11:14 Anonymous (not verified) 136.34.78.83 KALONA SALES BARN, INC. 191 9TH STREET; KALONA, IA 52247 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-07 DEVIN MULLET LMULLET@KALONASALESBARN.COM KALONA WASHINGTON IOWA ALANA MULLET ROCHELLE MULLET Signed (1) The corporation rejects the employers’ liability coverage. DEVIN MULLET LMULLET@KALONASALESBARN.COM OWNER KALONA WASHINGTON IOWA ALANA MULLET ROCHELLE MULLET Signed
166 2021-01-21 08:52 Anonymous (not verified) 66.102.212.10 English River Transport, Inc. 2015 Highway 22, Kalona, IA 52247 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-13 James A Yoder fisheria@kctc.net Kalona Washington IA Christian Swartzentruber Judy Showalter Signed (1) The corporation rejects the employers’ liability coverage. James A Yoder christian@fisherins.com President Kalona Washington IA Christian Swartzentruber Judy Showalter Signed
253 2021-05-04 16:17 Anonymous (not verified) 207.32.14.70 Experts Roofing LLC 8655 81st St S, Cottage Grove MN 55016 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. 2021-05-04 Victor Oropeza vikrosales@hotmail.com Cottage Grove Washington MN Emily Danner Michael Karels Signed (1) The corporation rejects the employers’ liability coverage. Victor Oropeza vikrosales@hotmail.com Owner Cottage Grove Washington MN Emily Danner Michael Karels Signed
276 2021-06-17 16:00 Anonymous (not verified) 204.155.61.217 Gentle Bend Inc 1075 120th Street Wellman, IA 52356 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. 2021-06-17 Greg Gent gentagincorporated@gmail.com Wellman Washington Iowa Jeff Spenner Shawn Powell Signed (1) The corporation rejects the employers’ liability coverage. Greg Gent gentagincorporated@gmail.com Owner Wellman Washington Iowa Jeff Spenner Shawn Powell Signed
350 2021-10-25 08:22 Anonymous (not verified) 208.95.64.3 Ron Sexton Construction Inc, 1184 Vine Ave, Riverside IA 52327 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-27 Ronald R Sexton ashmac@iowatelecom.net Riverside Washington IA Greg Martin Michele McMichael Signed (1) The corporation rejects the employers’ liability coverage. Ronald R Sexton ashmac@iowatelecom.net President Riverside Washington IA Greg Martin Michele McMichael Signed
351 2021-10-25 08:24 Anonymous (not verified) 208.95.64.3 Ron Sexton Construction Inc, 1184 Vine Ave, Riverside IA 52327 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-27 Theresa A Sexton ashmac@iowatelecom.net Riverside Washington IA Greg Martin Michele McMichael Signed (1) The corporation rejects the employers’ liability coverage. Theresa A Sexton ashmac@iowatelecom.net VP, Secretary, Treasurer Riverside Washington IA Greg Martin Michele McMichael Signed
474 2022-05-16 16:25 Anonymous (not verified) 208.126.193.1 Gentle Bend Inc. 1075 120th Street, Wellman, Iowa 52356 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-16 Georgia Gent ggent83@gmail.com Wellman Washington Iowa Jeff Spenner Shawn Powell Signed (1) The corporation rejects the employers’ liability coverage. Georgia Gent ggent83@gmail.com owner Wellman Washington Iowa Jeff Spenner Shawn Powell Signed
878 2024-02-02 15:22 Anonymous (not verified) 94.188.207.223 Open Road Driving School.com INC 2418 Paradise Ct Kalona, Iowa 52247 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-02-02 Ryan Turner ryanturner@citypoint.cc Kalona Washington IOwa Lonnie Slaubaugh Joshua Turner Signed (1) The corporation rejects the employers’ liability coverage. Ryan Turner ryanturner@citypoint.cc Secretary Kalona Washington Iowa Lonnie Slabaugh Joshua Turner Signed