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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:
809 2023-11-08 09:47 Anonymous (not verified) 94.188.207.229 GruntWorkz Wedling and Fab, Inc. 15519 80th Ave Blue Grass, IA 52726 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-08 Brandon Joseph Fox GruntWorkzwelding@gmail.com Blue Grass Scott Iowa Amanda Dawn Fox Brandon Joseph Fox Signed (1) The corporation rejects the employers’ liability coverage. Brandon Joseph Fox GruntWorkzwelding@gmail.com Same Person Blue Grass Scott Iowa Amanda Dawn Fox Brandon Joseph Fox Signed
263 2021-05-06 15:18 Anonymous (not verified) 174.243.113.232 Agronomic Solutions 908 E Dubuque St Quasqueton IA 52326 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. 2021-05-06 Brandy Hodges mapping@agsolutionsinc.net Coon Rapids IA United States Jacki Sloss Don Sloss Signed (1) The corporation rejects the employers’ liability coverage. Friday Insurance doug.miller@fridayinsurance.net agent Osceola Clarke IA Jacki Sloss Don Sloss Signed
392 2022-01-26 16:11 Anonymous (not verified) 207.199.212.86 Geerts Plumbing and Heating 913 N Linn Ave, New Hampton, IA 50659 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-07-21 Brenda Geerts lacy@cioia.com New Hampton Chickasaw Iowa Lacy Carolan Tony Trower Signed (1) The corporation rejects the employers’ liability coverage. Brenda Geerts lacy@cioia.com Owner New Hampton Chickasaw Iowa Lacy Carolan Tony Trower Signed
587 2023-01-09 10:04 Anonymous (not verified) 173.27.230.122 Hatfield Co Inc 307 E 20th St Box 185 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. 2023-01-09 Brenda Hatfield brenmarie137.bh@gmail.com Lovilia IA United States Jerry Griffin Dave Chesnut Signed (1) The corporation rejects the employers’ liability coverage. Boyle and Henderson joycem@boyleandhenderson.com Accountant Oskaloosa Marion Iowa Jerry Griffin Dave Chesnut Signed
85 2020-06-03 17:53 Anonymous (not verified) 75.162.69.231 Blackford Foundations Inc 501 SW Franklin Dr, Ankeny, IA 50023 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-05-01 Brenda Marie Blackford brendab@blackfordfoundations.com Ankeny Polk Iowa Saree Luce Ricky Eatwell Signed (1) The corporation rejects the employers’ liability coverage. Brenda Marie Blackford brendab@blackfordfoundations.com President Ankeny Polk Iowa Saree Luce Ricky Eatwell Signed
296 2021-07-29 08:51 Anonymous (not verified) 204.155.61.217 Blaine Management Inc 660 NE Dellwood Dr Apt 17, Waukee, IA 5063 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-07-29 Brent Ott brent@hailmayday.com Prior Lake Scott MN Ashley Kraft DocuSign Signed (1) The corporation rejects the employers’ liability coverage. Brent Ott Brent@hailmayday.com Owner Prior Lake Scott MN Ashley Kraft Docusign Signed
498 2022-06-17 08:45 Anonymous (not verified) 64.5.79.180 The Sign Shed & Graphics LLC 529 Erie St, PO Box 252 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. 2022-05-26 Brent Ulrich signshed@yahoo.com Storm Lake IA United States Zach Ruroden Ryan Young Signed (1) The corporation rejects the employers’ liability coverage. Brent Ulrich signshed@yahoo.com CEO Storm Lake IA United States Zach Ruroden Ryan Young Signed
960 2024-04-22 18:25 Anonymous (not verified) 94.188.205.174 Balvanz Electric LLC 1517 Greenfield Dr I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-22 Brenton Balvanz balvanzelectric@gmail.com Marshalltown Marshall Iowa Christin Branon Justin Branon Signed (1) The corporation rejects the employers’ liability coverage. Brenton Balvanzelectric@gmail.com Owner/President Marshalltown Marshall Iowa Christin Branon Justin Branon 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
514 2022-07-15 11:51 Anonymous (not verified) 50.80.230.95 CRV, Inc 1607 LaPorte Rd Waterloo, IA 50702 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. 2022-07-15 Brett Allyn Corpman priorityone@thewebunwired.com Waterloo Black Hawk Iowa John W Vinton Stephen A Brustkern Signed (1) The corporation rejects the employers’ liability coverage. Brett Allyn Corpman priorityone@thewebunwired.com Officer Waterloo Black Hawk IA John W Vinton Stephen A Brustkern 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
625 2023-03-09 10:27 Anonymous (not verified) 94.188.207.230 River City Transport, Inc 201 Lezlie 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. 2023-03-09 Brian Brewer brian@rivercitylogistics.net Sparks Washoe Nevada Jacob Shireman Matthew Gazzola Signed (1) The corporation rejects the employers’ liability coverage. Brian Brewer brian@rivercitylogistics.net Vice President Sparks Washoe Nevada Jacob Shireman Matthew Gazzola Signed
575 2022-11-18 14:01 Anonymous (not verified) 204.155.61.217 County Line Drainage Inc 806 Milton Ave, Lake Mills, IA 50450 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. 2022-11-18 Brian Helgeson dgust@mbtbank.com Lake Mills Winnebago Iowa Douglas Gust Lee Lambert Signed (1) The corporation rejects the employers’ liability coverage. Brian Helgeson brianshelgeson@gmail.com President Lake mills Winnebago Iowa Douglas Gust Lee Lambert Signed
705 2023-07-06 14:24 Anonymous (not verified) 94.188.205.167 Portwood H3D Consulting 1109 295th Street, Oxford Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-06 Brian Portwood portwoodh3dconsulting@gmail.com Oxford Johnson Iowa Bob Herring Chelsey Atkinson Signed (1) The corporation rejects the employers’ liability coverage. Brian Portwood portwoodh3dconsulting@gmail.com owner Oxford Johnson Iowa Bob Herring Chelsey Atkinson Signed
219 2021-03-29 08:05 Anonymous (not verified) 173.18.193.51 Lee County Fair, Inc PO Box 179, Donnellson, Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-03 Brock Westfall judy@fullenkampins.com Montrose Lee Iowa Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Brock Westfall judy@fullenkampins.com Board Member Montrose Lee Iowa Lindsey Lampe Judy Moeller Signed
424 2022-03-11 15:36 Anonymous (not verified) 69.63.16.2 BR Flynn Co Inc 16756 Corey Daniel Ct, 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. 2022-03-11 Bruce R Flynn br.flynn4@gmail.com Dubuque Dubuque Iowa Rick Meyer Dyan Kriener Signed (1) The corporation rejects the employers’ liability coverage. Bruce R Flynn br.flynn4@gmail.com President Dubuque Dubuque IA Rick Meyer Dyan Kriener Signed
61 2020-04-20 13:13 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 Bruce Tamisiea jennifer@walkerinsuranceia.com Wahpeton Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Bruce Tamisiea jennifer@walkerinsuranceia.com Board Member Wahpeton Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
216 2021-03-29 08:01 Anonymous (not verified) 173.18.193.51 Lee County Fair, Inc PO Box 179, Donnellson, IOwa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-03-03 Bryan Bredemeyer judy@fullenkampins.com Bonaparte IA United States Lindsey Lampe Judy Moeller Signed (1) The corporation rejects the employers’ liability coverage. Brian Bredemeyer judy@fullenkampins.com Board Member Bonaparte IA United States Lindsey Lampe Judy Moeller Signed
470 2022-05-12 14:28 Anonymous (not verified) 173.184.134.123 Bryce Hoffert LLC 1802 Lake Street Emmetsburg Iowa 50536 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. 2022-05-12 Bryce C Hoffert brycehoffertllc@gmail.com Emmetsburg Pala Alto Iowa Ray Hoffert Shelbie Hurdle Signed (1) The corporation rejects the employers’ liability coverage. Bryce Hoffert brycehoffertllc@gmail.com member Emmetsburg Palo Alto Iowa Ray Hoffert Shelbie Hurdle 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
948 2024-04-05 16:18 Anonymous (not verified) 94.188.205.168 Preventive Health Center of Iowa City, PLLC 221 E College St, Suite 211, Eastwind Healing Center, Iowa City, IA 52240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-05 C Andi Woods phcic52240@gmail.com Iowa City Johnson ia Nancy Martin Timmy Ungs Signed (1) The corporation rejects the employers’ liability coverage. C Andi Woods phcic52240@gmail.com Owner Iowa City Johnson IA Nancy Martin Timmy Ungs Signed
316 2021-08-23 10:15 Anonymous (not verified) 70.119.220.61 Iles Funeral Homes Inc. 6337 Hickman Rd, Des Moines, IA 50322 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-07-07 C Michael Iles mike.iles@ilesscares.com Heath Rockwall Texas Susan Lancaster Kathryn Mann Signed (1) The corporation rejects the employers’ liability coverage. C Michael Iles mike.iles@ilescares.com Vice President Heath Rockwall Texas Susan Lancaster Kathryn Mann Signed
404 2022-02-13 12:50 Anonymous (not verified) 217.180.228.177 Premier Property Group LLC 8805 Chambery Blvd Ste 300 #217 Johnston, IA 50131 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-02-13 Cade Montgomery ppgiowallc@gmail.com Johnston Polk Iowa Cailey Montgomery Sara Saylor Signed (1) The corporation rejects the employers’ liability coverage. Cade Montgomery ppgiowallc@gmail.com Owner Johnston Polk Iowa Cailey Montgomery Sara Saylor Signed
875 2024-01-30 14:18 Anonymous (not verified) 94.188.207.226 Central Athletics LLC 7 S 4th Street Council Bluffs Iowa 51503 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-30 Cait Boyer centralathleticsia@gmail.com Council Bluffs Pottawattamie Iowa Justice Woolard Erin Eby Signed (1) The corporation rejects the employers’ liability coverage. Cait Boyer centralathleticsia@gmail.com President Council Bluffs Pottawattamie Iowa Justice Woolard Erin Eby Signed
34 2020-01-16 13:10 Anonymous (not verified) 108.171.132.188 B & C Lawn Care Inc P.O. Box 55, Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-01-01 Caleb Elliott onethird4599@gmail.com Boone Boone Iowa Katie Frame Jessica Carroll Signed (1) The corporation rejects the employers’ liability coverage. Caleb Elliott onethird4599@gmail.com Owner Boone Boone IOWA Katie Frame Jessica Carroll Signed
101 2020-07-16 13:07 Anonymous (not verified) 173.28.28.57 Weikert Properties, LLC 34520 175th Street, Cedar Falls IA 5061 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. 2020-06-23 Caleb Weikert cmins_re@mchsi.com Cedar Falls Grundy Iowa Chad Campbell Roxanne Kolder Signed (1) The corporation rejects the employers’ liability coverage. Caleb Weikert cmins_re@mchsi.com Self Cedar Falls Grundy Iowa Chad Campbell Roxanne Kolder Signed
703 2023-06-27 07:05 Anonymous (not verified) 94.188.207.229 Dancom Inc 1001 Office Park Rd, West Des Moines, IA 50265 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. 2023-06-26 Calvin Otundo calvin@dancoms.com Waukee Polk IA Joe Meyers Robert Simmons Signed (1) The corporation rejects the employers’ liability coverage. Calvin Otundo calvin@dancoms.com Owner Waukee Polk IA Robert Simmons Joe Meyers Signed
288 2021-07-22 16:17 Anonymous (not verified) 104.166.243.230 Renewal By Anderson 517 railroad ave. West Des Moines I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-07-22 Cameron Thede camthede22@gmail.com Windsor Heights Polk Iowa Mac Laven sdofkn Signed (1) The corporation rejects the employers’ liability coverage. Renewal By Andersen james@rbadesmoines.com Subcontractor West Des Moines Polk IA Mac Laven lsdfkn lsadnf Signed
441 2022-04-11 13:15 Anonymous (not verified) 75.162.175.12 Castro construction LLC 1712 carpenter av desmoines Iowa 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-11 Carlos Alberto castro Alcántara castrodvxhd@gmail.com Estados Unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe padilla bonilla Signed (1) The corporation rejects the employers’ liability coverage. Carlos Alberto castro Alcántara castrodvxhd@gmail.com Owner Estados unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe Padilla Bonilla Signed
442 2022-04-11 13:15 Anonymous (not verified) 75.162.175.12 Castro construction LLC 1712 carpenter av desmoines Iowa 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-11 Carlos Alberto castro Alcántara castrodvxhd@gmail.com Estados Unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe padilla bonilla Signed (1) The corporation rejects the employers’ liability coverage. Carlos Alberto castro Alcántara castrodvxhd@gmail.com Owner Estados unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe Padilla Bonilla Signed
443 2022-04-11 13:15 Anonymous (not verified) 75.162.175.12 Castro construction LLC 1712 carpenter av desmoines Iowa 50314 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-11 Carlos Alberto castro Alcántara castrodvxhd@gmail.com Estados Unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe padilla bonilla Signed (1) The corporation rejects the employers’ liability coverage. Carlos Alberto castro Alcántara castrodvxhd@gmail.com Owner Estados unidos Iowa Desmoines Blanca Yadira montes Quiñones Maynor Noe Padilla Bonilla Signed
299 2021-08-02 10:55 Anonymous (not verified) 97.125.35.240 L:ion BUilder Construction,, INC 1705 E 32nd St Des Moines, Iowa 50317 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-07-24 Carlos E Mondoza-Gutierrez gutierrezce1992@icloud.com Des Moines Polk Iowa Debra Stratton Juana M.R. Signed (1) The corporation rejects the employers’ liability coverage. Carlos E Mendoz-Gutierrez gutierrezce1992@icloud.com self Des Moines Polk Iowa Juan M. R. Debra Stratton Signed
606 2023-02-20 20:55 Anonymous (not verified) 94.188.205.168 Carlos Ortiz LLC 4335 NE 23rd Ave Des Moines, IA 50317 Estados Unidos 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. 2023-02-20 Carlos Ortiz carlosoframing@gmail.com Des Moines Polk Iowa Luz picazo Brando ortiz Signed (1) The corporation rejects the employers’ liability coverage. Carlos Ortiz carlosograming@gmail.com Owner Des Moines Polk Iowa Luz picazo Brando Ortiz 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
860 2024-01-19 08:59 Anonymous (not verified) 94.188.205.168 T&R Drywall LLC 1450 NE 69th Pl Ste 56 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. (1) I reject the employers’ liability coverage. 2024-01-19 Carmelo Chavez Special.t.d@hotmail.com Des Moines Polk Iowa Omar L Tippetts Omar L Tippetts Jr Signed (1) The corporation rejects the employers’ liability coverage. N/A special.t.d@hotmail.com N/A N/A N/A N/A N/A N/A Signed
444 2022-04-14 15:50 Anonymous (not verified) 72.10.21.42 Babcock Services Idaho, Inc. 8113 W QUINAULT AVENUE 201, Kennewick, WA 99336 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-14 Carmen Clyde CCLYDE@BABCOCKSERVICES.COM KENNEWICK WA Washington Linda McAlister Cesar Jimenez Signed (1) The corporation rejects the employers’ liability coverage. CARMEN CLYDE CCLYDE@BABCOCKSERVICES.COM Secretary KENNEWICK Benton Washington Linda McAlister Cesar Jimenez Signed
479 2022-05-26 14:05 Anonymous (not verified) 71.28.218.225 TRAER MUSEUM 514 2ND ST. TRAER, IA 50675 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. 2022-05-26 Carol Boyce carolwoodboyce@gmail.com Dysart Tama IOWA EDWARD HOEG KIM DAHMS Signed (1) The corporation rejects the employers’ liability coverage. CAROL BOYCE carolwoodboyce@gmail.com VICE PRESIDENT Dysart Tama IOWA ED HOEG KIM DAHMS Signed
109 2020-08-24 14:41 Anonymous (not verified) 74.84.91.178 Rotten Love LLC 1101 Valentine Drive, Dubuque, IA 52003 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-08-14 Carolyn Schmid rottenlovellc@gmail.com Dubuque Dubuque Iowa Brenda Lewis Sue Miller Signed (1) The corporation rejects the employers’ liability coverage. Carolyn Schmid rottenlovellc@gmail.com partner Dubuque Dubuque IA Brenda Lewis Sue Miller Signed
426 2022-03-22 12:06 Anonymous (not verified) 69.54.105.130 Downing Development, Ltd. 13004 NW 44th St Polk City, IA 50226 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-03-22 Carolyn Suzanne Downing susiedowningdevelopment@gmail.com Polk City IA United States Geneva Aki Ross Amy Sue Romero Signed (1) The corporation rejects the employers’ liability coverage. Carolyn Suzanne Downing susiedowningdevelopment@gmail.com Secretary Polk City Polk County Iowa Geneva Aki Ross Amy Sue Romero Signed
590 2023-01-18 15:14 Anonymous (not verified) 172.86.13.54 BOLT HOLDINGS, Inc and Holt Precision dba Holt Bladeworks and Holt Kinetic Solutions 3230 N Center Point 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. 2023-01-18 Carter Kramer Carter@Holtkineticsolutions.com Cedar Rapids Linn Iowa Lisa Gleason Tricia Kummer Signed (1) The corporation rejects the employers’ liability coverage. Lisa Gleason Lisa@Holtkineticsolutions.com General Manager Marion Linn Iowa Tricia Kummer Marla McFall Signed
774 2023-09-21 10:21 Anonymous (not verified) 94.188.205.167 Tri State Trucking LLC 47282 US Hwy 20 Atkinson, NE 68713 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. 2023-09-21 Casey Schaaf casey@tri-statetrucking.com Atkinson Holt NE Angela Schaaf Crystal Osborne Signed (1) The corporation rejects the employers’ liability coverage. Casey Schaaf casey@tri-statetrucking.com Owner Atkinson Holt NE Angela Schaaf Crystal Osborne Signed
568 2022-11-15 08:23 Anonymous (not verified) 174.215.243.6 Cesar rolando Acosta rivera 2080 king ave apt 21 Des Moines ia 50320 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-15 Cesar rolando Acosta Rivera acostariveracesarrolando@gmail.com Des Moines Iowa Polk Iowa Juan acosta Antonio acosta Signed (1) The corporation rejects the employers’ liability coverage. Cesar rolando Acosta Rivera acostariveracesarrolando@gmail.com Owner Des moines Polk Iowa Juan acosta Antonio acosta Signed
569 2022-11-15 08:23 Anonymous (not verified) 174.215.243.6 Cesar rolando Acosta rivera 2080 king ave apt 21 Des Moines ia 50320 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-15 Cesar rolando Acosta Rivera acostariveracesarrolando@gmail.com Des Moines Iowa Polk Iowa Juan acosta Antonio acosta Signed (1) The corporation rejects the employers’ liability coverage. Cesar rolando Acosta Rivera acostariveracesarrolando@gmail.com Owner Des moines Polk Iowa Juan acosta Antonio acosta Signed
709 2023-07-17 15:46 Anonymous (not verified) 94.188.205.166 Breuer Roofing Company 3021 Sunburst Dr. Bettendorf, IA 52722 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-17 Chad Breuer chadbreuer@gmail.com Bettendorf Scott IA Caroline Kristina Breuer Patricia Ann Breuer Signed (1) The corporation rejects the employers’ liability coverage. Chad Michael Breuer chadbreuer@gmail.com President Bettendorf Scott IA Caroline Kristina Breuer Patricia Ann Breuer Signed
290 2021-07-26 12:29 Anonymous (not verified) 208.95.1.97 Chyma's Welding, Inc. 206 2nd Ave, Toledo IA 52342 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-08-01 Chad Chyma Chymamenwelding@windstream.net Toledo Tama IA Matt Zmolek Michaela Chyma Signed (1) The corporation rejects the employers’ liability coverage. Chad Chymamenwelding@windstream.net Director Toledo IA United States Matt Zmolek Michaela Chyma Signed
291 2021-07-26 12:31 Anonymous (not verified) 208.95.1.97 Chyma's Welding, Inc. 206 2nd Ave, Toledo IA 52342 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. 2021-08-01 Chad Chyma Chymamenwelding@windstream.net Toledo Tama Iowa Matt Zmolek Michaela Chyma Signed (1) The corporation rejects the employers’ liability coverage. Chad Chyma Chymamenwelding@windstream.net Director Toledo Tama Iowa Matt Zmolek Michaela Chyma Signed
292 2021-07-26 12:38 Anonymous (not verified) 208.95.1.97 Chyma's Machine and Welding Shop, Inc. 206 2nd Ave, Toledo IA 52342 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-08-01 Chad Chyma Chymamenwelding@windstream.net Toledo Tama Iowa Matt Zmolek Michaela Chyma Signed (1) The corporation rejects the employers’ liability coverage. Chad Chyma Chymamenwelding@windstream.net Director Toledo Tama Iowa Matt Zmolek Michaela Chyma Signed
293 2021-07-26 12:39 Anonymous (not verified) 208.95.1.97 Chyma's Machine and Welding Shop, Inc. 206 2nd Ave, Toledo IA 52342 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. 2021-08-01 Chad Chyma Chymamenwelding@windstream.net Toledo Tama Iowa Matt Zmolek Michaela Chyma Signed (1) The corporation rejects the employers’ liability coverage. Chad Chyma Chymamenwelding@windstream.net Director Toledo Tama IA Matt Zmolek Michaela Chyma Signed
579 2022-12-07 14:37 Anonymous (not verified) 96.31.1.206 IGL RENTAL LLC PO BOX 317 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. 2022-10-25 CHAD JONES STAYBOJI@GMAIL.COM ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The corporation rejects the employers’ liability coverage. CHAD JONES STAYBOJI@GMAIL.COM MEMBER ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
810 2023-11-09 17:41 Anonymous (not verified) 94.188.205.167 Chad Ripple's Painting LLC 899 NW 45th 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. 2023-11-09 Chad Ripple ia515@hotmail.com Des Moines Polk Iowa Ron Spurgeon Brandon Haus Signed (1) The corporation rejects the employers’ liability coverage. Chad Ripple ia515@hotmail.com President Des Moines Polk Iowa Ron Spurgeon Brandon Haus Signed