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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:
228 2021-04-05 13:06 Anonymous (not verified) 173.18.193.51 Houghton Cedar Township Fire Department 1135 140th Avenue, Salem, Iowa 52649 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-03 Brad Vandenberg judy@fullenkampins.com Donnellson Lee Iowa Judy Moeller Shelby Green Signed (1) The corporation rejects the employers’ liability coverage. Brad Vandenberg judy@fullenkampins.com Board Member Salem Lee Iowa Judy Moeller Shelby Green 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
966 2024-04-30 14:39 Anonymous (not verified) 94.188.207.230 Bowman Dozing & Excavating LLC 218 134th ave Maquoketa, IA 52060 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. 2024-04-30 Bradley D Bowman dozermann9@hotmail.com Maquoketa Jackson Iowa Jennifer Machande Mitchell Schaller Signed (1) The corporation rejects the employers’ liability coverage. Bradley D Bowmann dozermann9@hotmail.com owner/president maquoketa Jackson iowa Jennifer Machande Mitch Schaller Signed
844 2023-12-29 08:28 Anonymous (not verified) 94.188.207.226 Emcubed Enterprises, Inc 979 40th Ave, Bettendorf, IA 52722 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-29 Bradley David Morrison brad@riverbendsignworks.com Moline Rock Island IL David Rodriguez Lisbet Lule Signed (1) The corporation rejects the employers’ liability coverage. Bradley David Morrison brad@riverbendsignworks.com Owner Moline Rock Island IL David Rodriguez Lisbet Lule Signed
91 2020-06-17 17:47 Anonymous (not verified) 166.182.83.28 BJJ Painting Inc 6940 Rolling Ridge CT SW Cedar Rapids IA 52404 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-06-17 Bradley Johnson brad.johnson@fivestarpainting.com Cedar Rapids Linn Iowa Mike McClure Tony Gaiffe Signed (1) The corporation rejects the employers’ liability coverage. Bradley Johnson brad.johnson@fivestarpainting.com President Cedar Rapids Linn Iowa Mike McClure Tony Gaiffe Signed
906 2024-02-29 16:16 Anonymous (not verified) 94.188.205.168 Bradley K. Gaul Handyman Services 740 Cedar Valley Road, Tipton, IA 52772 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. 2024-02-29 Bradley Keith Gaul bjgjal33@aol.com Tipton Cedar Iowa Jill Lynette Gaul Logan Benjamin Gaul Signed (1) The corporation rejects the employers’ liability coverage. Bradley Keith Gaul bjgjal33@aol.com Self Tipton Cedar Iowa Jill Lynette Gaul Logan Benjamin Gaul Signed
182 2021-02-18 08:52 Anonymous (not verified) 173.18.193.51 Freeman Family Farms Inc 3125 Glasgow Rd Fairfield Iowa 52556 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. 2021-02-08 Bradly Freeman jill@fullenkampins.com Mt. Pleasant Henry Iowa Jill A Garmoe Judy K Moeller Signed (1) The corporation rejects the employers’ liability coverage. Bradly Freeman jill@fullenkampins.com Treasurer Mt Pleasant Henry Iowa Jill A Garmoe Judy K Moeller Signed
603 2023-02-16 16:11 Anonymous (not verified) 94.188.207.223 Transcend Mind Body Wellness and Floatation Clinic 409 Washington Street, Cedar Falls, IA 50613 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. 2023-01-01 Morgan Huls transcendcedarfalls@gmail.com Cedar Falls Black Hawk Iowa Brady Huls Ashlyn Henry Signed (1) The corporation rejects the employers’ liability coverage. Brady Huls transcendcfo@gmail.com CFO Cedar Falls Black Hawk Iowa Morgan Huls Ashlyn Henry 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
842 2023-12-18 16:31 Anonymous (not verified) 94.188.205.168 Brandon Clement 3503 South Union St I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-18 Brandon Clement hawthornhill@paramark.us Des Moines Polk IA Brandi Haight Amanda Thompson Signed (1) The corporation rejects the employers’ liability coverage. Brandon Clement hawthornhill@paramark.us none Des Moines polk IA Brandi Haight Amanda Thompson Signed
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
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
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
600 2023-02-16 16:06 Anonymous (not verified) 94.188.207.225 Friday After Work LLC 2526 Rainbow Drive, Cedar Falls, IA 50613 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. 2023-01-01 Joshua Carder josh.cve@gmail.com Cedar Falls Black Hawk Iowa Brady Huls Tyler Reynolds Signed (1) The corporation rejects the employers’ liability coverage. Brent Dunlop fawconstruction.ia@gmail.com Owner Cedar Falls Black Hawk Iowa Brady Huls Tyler Reynolds Signed
601 2023-02-16 16:08 Anonymous (not verified) 94.188.207.223 Friday After Work LLC 2526 Rainbow Drive, Cedar Falls, IA 50613 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. 2023-01-01 Tyler Reynolds tyler.cve@gmail.com Cedar Falls Black Hawk Iowa Brady Huls Joshua Carder Signed (1) The corporation rejects the employers’ liability coverage. Brent Dunlop fawconstruction.ia@gmail.com Owner Cedar Falls Black Hawk Iowa Brady Huls Joshua Carder Signed
602 2023-02-16 16:10 Anonymous (not verified) 94.188.207.228 Friday After Work LLC 2526 Rainbow Drive, Cedar Falls, IA 50613 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. 2023-01-01 Brady John Huls brady.cve@gmail.com Cedar Falls Black Hawk Iowa Tyler Reynolds Joshua Carder Signed (1) The corporation rejects the employers’ liability coverage. Brent Dunlop fawconstruction.ia@gmail.com Owner Cedar Falls Black Hawk Iowa Tyler Reynolds Joshua Carder 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
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
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
306 2021-08-11 17:03 Anonymous (not verified) 208.73.53.194 Dave Sturges Trucking Inc 16244 170th St. Rockwell, IA 50469 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. 2021-08-11 Joseph d sturges sturgtrucking@gmail.com Rockwell, IA Cerro Gordo IA Connie Downing Darc Schropshire Signed (1) The corporation rejects the employers’ liability coverage. Brian Sturges briansturges@netins.net President Rockwell, Ia Cerro Gordo IA Connie Downing Darc Schropshire 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
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
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
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
317 2021-08-23 10:19 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 Mark Iles mark.iles@ilescares.com Clive Polk Iowa Lori Crabb Paul Marshall 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
967 2024-05-01 06:30 Anonymous (not verified) 94.188.207.224 Cael Gulrud 206 W Main St Calmar, IA, 52132 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. 2024-05-01 Brandon Gulrud mojopants21@gmail.com Waterloo Blackhawk IA Victoria Bacon-Ortiz David Gulrud Signed (1) The corporation rejects the employers’ liability coverage. Cael Gulrud gulrud8728@gmail.com Owner Calmar Winneshiek IA Victoria Bacon-Ortiz David Gulrud 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
75 2020-04-29 11:07 Anonymous (not verified) 107.77.206.22 ACR Construction, Inc 7330 NW 21 St. 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. 2020-04-29 Andre Sean Drost andre.drost@acr-construction-inc.com Ankeny Polk IA Heidi Smith Jeff Smith Signed (1) The corporation rejects the employers’ liability coverage. Candace Drost acrdrost@hotmail.com President Ankeny Polk IA Heidi Smith Jeff Smith 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
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
445 2022-04-14 15:52 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 Keith Myers CCLYDE@BABCOCKSERVICES.COM KENNEWICK Benton 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