954 |
2024-04-08 17:38 |
Anonymous (not verified) |
94.188.205.168 |
Bio-Inspired Design Aeronautics Corp |
6843 Still Creek Pass |
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. |
2024-03-08 |
Hailey Mitchell |
hailey8.hm@hush.com |
Bettendorf |
Iowa |
United States |
Mike Owens |
Chris DeCock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Mitchell |
aerotech@hush.com |
President |
Bettendorf |
Iowa |
United States |
Mike Minnich |
Chris DeCock |
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 |
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 |
86 |
2020-06-03 17:56 |
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 |
Denny Lee Blackford |
blackfordfoundations@gmail.com |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Denny Lee Blackford |
blackfordfoundations@gmail.com |
Secretary |
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 |
231 |
2021-04-11 12:19 |
Anonymous (not verified) |
174.243.115.140 |
Blaser Plumbing Inc |
28933 Sieverding Ridge Rd Bellevue IA 52031 |
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. |
2021-04-11 |
Michael Blaser |
bpi1999@hotmail.com |
Bellevue |
IA |
United States |
Joyce Langmeier |
Sylvester Langmeier |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Blaser |
bpi1999@hotmail.com |
Owner |
Bellevue |
IA |
United States |
Joyce Langmeier |
Sylvester Langmeier |
Signed |
763 |
2023-09-05 12:31 |
Anonymous (not verified) |
94.188.205.168 |
Blue Ridge Enterprises, LLC |
604 old sixteen road Waterville, IA 52170 |
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. |
2023-09-05 |
Nathan Eldon Leas |
nleas69@gmail.com |
Waterville |
Allamakee |
Iowa |
Mark Wright |
Gary Mahr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nathan Eldon Leas |
nleas69@gmail.com |
President/owner |
Waterville |
Allamakee |
Iowa |
Mark Wright |
Gary Mahr |
Signed |
107 |
2020-08-04 13:42 |
Anonymous (not verified) |
97.64.131.90 |
BNR Construction INC |
210 4th St Orient, IA 50858 |
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. |
2020-08-04 |
Bennie Shinn |
bnrconstllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
111 |
2020-08-25 14:37 |
Anonymous (not verified) |
204.155.61.217 |
BNR Construction INC |
210 4th St Orient,Ia 50858 |
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. |
2020-07-15 |
Bennie Shinn |
bnrconstructllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstructllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
112 |
2020-08-26 10:18 |
Anonymous (not verified) |
97.64.131.90 |
BNR Construction INC |
210 4th St Orient, IA 50858 |
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. |
2020-07-15 |
Bennie Shinn |
bnrconstllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
21 |
2019-12-30 11:28 |
Anonymous (not verified) |
207.191.194.182 |
Bob Stephen Motors Inc |
324 W Main St, Manchester IA 52057 |
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. |
2019-11-05 |
Paul Roussell |
twyladetrich@gmail.com |
MANCHESTER |
DELAWARE |
IA |
Traci Lyons |
Allie DeVore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Heidi Roussell |
twyladetrich@gmail.com |
Vice President |
Manchester |
DELAWARE |
IA |
Traci Lyons |
Allie DeVore |
Signed |
22 |
2019-12-30 11:30 |
Anonymous (not verified) |
207.191.194.182 |
Bob Stephen Motors Inc |
324 West Main St, Manchester IA 52057 |
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. |
2019-11-05 |
Heidi Roussell |
twyladetrich@gmail.com |
Manchester |
DELAWARE |
IA |
Traci Lyons |
Allie DeVore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Roussell |
twyladetrich@gmail.com |
President |
MANCHESTER |
Delaware |
IA |
Traci Lyons |
Allie DeVore |
Signed |
712 |
2023-07-24 12:34 |
Anonymous (not verified) |
94.188.205.168 |
BOG Roofing |
3768 Deerbrook Dr |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-24 |
Devon Booton |
devonboot1973@gmail.com |
Bettendorf |
Iowa |
United States |
Viviana Gonzalez |
Shannon Wolever |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Devon Booton |
devonboot1973@gmail.com |
Self |
Bettendorf |
Iowa |
United States |
Viviana Gonzalez |
Shannon Wolever |
Signed |
248 |
2021-04-29 09:59 |
Anonymous (not verified) |
173.31.147.225 |
BOJI CUSTOM METAL WORKS INC |
402 E 4TH ST SPENCER, IA 51301 |
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. |
2021-04-23 |
SCOTT PYLE |
scottpyle98@hotmail.com |
FOSTORIA |
CLAY |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
SCOTT PYLE |
joel@walkerinsuranceia.com |
PRESIDENT |
FOSTORIA |
CLAY |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
475 |
2022-05-19 10:11 |
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 Unit 204, Marion, IA 52302 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-19 |
Angey Holt |
Angey@Holtkineticsolutions.com |
Robins |
Linn |
Iowa |
Lisa Gleason |
Danielle Congleton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Gleason |
Lisa@holtkineticsolutions.com |
General Manager |
Marion |
Linn |
Iowa |
Danielle Congleton |
Joe Holt |
Signed |
476 |
2022-05-19 11:45 |
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 Unit 204, Marion, IA 52302 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-19 |
Joseph Holt |
Joe@kineticsolutons.com |
Robins |
Linn |
Iowa |
Lisa Gleason |
Danielle Congleton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Gleason |
Lisa@holtkineticsolutions.com |
General Manager |
Marion |
Linn |
Iowa |
Danielle Congleton |
Angey Holt |
Signed |
477 |
2022-05-19 11:49 |
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 Unit 204, Marion, IA 52302 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-19 |
Ben Congleton |
Ben@holtkineticsolutions.com |
Cedar Rapids |
Linn |
Iowa |
Lisa Gleason |
Angey Holt |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Gleason |
Lisa@holtkineticsolutions.com |
General Manager |
Marion |
Linn |
Iowa |
Lisa Gleason |
Danielle Congleton |
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 |
873 |
2024-01-26 12:02 |
Anonymous (not verified) |
94.188.207.224 |
Bowlerama, Inc. |
1313 East Diehl St. Des Moines, IA 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-26 |
Michael Klimpel |
Klimpel@aol.com |
Rosemount |
MN |
United States |
Eric Stahl |
Connie Hill |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Michael Klimpel |
Klimpel@aol.com |
President |
Rosemount |
MN |
United States |
Eric Stahl |
Connie Hill |
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 |
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 |
656 |
2023-04-19 10:46 |
Anonymous (not verified) |
94.188.205.174 |
Brad Anthony Logging LLC |
307 Commercial St, Strawberry Point IA 52076 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-18 |
Brad Anthony |
banthony6487@gmail.com |
Strawberry Point |
Clayton |
Iowa |
Roger Gibbs |
Mitzi Hoeger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brad Anthony |
banthony6487@gmail.com |
Self |
Strawberry Point |
Clayton |
Iowa |
Mitzi Hoeger |
Roger Gibbs |
Signed |
526 |
2022-08-17 11:16 |
Anonymous (not verified) |
173.27.233.86 |
Bradens Roofing and Construction Llc |
2450 Hart Avenue |
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. |
2022-08-17 |
Arsenio Vargas Velazquez |
avargas409@gmail.com |
Des Moines |
polk |
Iowa |
Julissa Dionicio |
Jennifer Dionicio |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Arsenio Vargas Velazquez |
avargas409@gmail.com |
owner |
Des Moines |
Polk |
Iowa |
Julissa Dionicio |
Jennifer Dionicio |
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 |
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 |
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 |
366 |
2021-11-23 12:20 |
Anonymous (not verified) |
173.19.234.191 |
Brezina Homes, Inc |
9008 NW 73rd Place, 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. |
2021-11-23 |
Allen J. Brezina |
a.brezina@mchsi.com |
Johnston |
Polk |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Allen J. Brezina |
a.brezina@mchsi.com |
President |
Johnston |
Polk |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
367 |
2021-11-23 12:23 |
Anonymous (not verified) |
173.19.234.191 |
Brezina Homes, Inc |
9008 NW 73rd Place, 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. |
2021-11-23 |
Monica M. Brezina |
a.brezina@mchsi.com |
Johnston |
Polk |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Allen J. Brezina |
a.brezina@mchsi.com |
President |
Johnston |
Polk |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
369 |
2021-11-30 09:37 |
Anonymous (not verified) |
173.19.234.191 |
Brezina Homes, Inc |
9008 NW 73rd Place, 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. |
2021-11-30 |
Anthony L. Brezina |
Tony.brezina@cbdsm.com |
West Des Moines |
Dallas |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Allen J. Brezina |
a.brezina@mchsi.com |
President |
Johnston |
Polk |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
382 |
2022-01-05 14:05 |
Anonymous (not verified) |
173.19.234.191 |
Brezina Homes, Inc |
9008 NW 73rd Place, 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. |
2022-01-05 |
Jennifer Brezina |
Jenniferfisher71979@gmail.com |
West Des Moines |
Dallas |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Allen J. Brezina |
a.brezina@mchsi.com |
President |
Johnston |
Polk |
Iowa |
Christopher Winterboer |
Melissa Winterboer |
Signed |
385 |
2022-01-11 08:27 |
Anonymous (not verified) |
173.29.238.103 |
Brilliant All-Seasons Lighting Inc. |
10357 NW 42nd 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. |
2022-01-11 |
Bradley Harold Loney |
bloney@live.com |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Katrina Loney |
katrinaloney@outlook.com |
Vice President |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
386 |
2022-01-11 08:30 |
Anonymous (not verified) |
173.29.238.103 |
Brilliant All-Seasons Lighting Inc. |
10357 NW 42nd 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. |
(2) I decline to reject the employer’s liability coverage. |
2022-01-11 |
Katrina Marie Loney |
katrinaloney@outlook.com |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Brad Loney |
bloney@live.com |
President |
Polk City |
Polk |
Iowa |
Linda Delin |
Amanda Warywoda |
Signed |
924 |
2024-03-19 16:40 |
Anonymous (not verified) |
94.188.207.228 |
Brite-Way Services Inc. |
621 Morningside Dr., Burlington IA 52601 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-19 |
Richard Luckenbill |
britewayburl@gmail.com |
Burlington |
Iowa |
Iowa |
Tammy Luckenbill |
Brooke Mathiasmeier |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Richard Luckenbill |
britewayburl@gmail.com |
Owner, President |
Burlington |
Iowa |
Iowa |
Tammy Luckenbill |
Brooke Mathiasmeier |
Signed |
116 |
2020-09-11 11:42 |
Anonymous (not verified) |
69.57.22.68 |
Brush and Weed Control Specialists, Inc. |
1108 230th Street - Algona, IA 50511 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-11 |
Ruth Jean Lindgren |
bwcontrol@netamumail.com |
Algona |
Kossuth |
Iowa |
James Black |
Katie Melvin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Donald H Reffer |
bwcontrol@netamumail.com |
President and General Manager |
Algona |
Kossuth |
Iowa |
James Black |
Katie Melvin |
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 |
768 |
2023-09-12 12:48 |
Anonymous (not verified) |
94.188.207.224 |
BSSI MW |
23959 580th 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. |
2023-08-28 |
Tom Barragy |
tom@agvolution.co |
Ames |
Boone |
Iowa |
Blaine Bancks |
Pete Romig |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Thomas j Barragy |
tbarragy@agvolution.co |
ownet |
AMES |
Boone |
ia |
Blaine Bancks |
Pete Romig |
Signed |
372 |
2021-12-09 14:17 |
Anonymous (not verified) |
204.155.61.217 |
Buena Vista Auto Sales Inc |
1030 Lake Ave, Storm Lake, IA 50588 |
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. |
2021-12-09 |
Arturo Lozano |
bvusedcars@siouxland.com |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Michelle Munoz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Arturo Lozano |
bvusedcars@siouxland.com |
Owner |
storm Lake |
Buena Vista |
IA |
Jared Brashears |
Michelle Munoz |
Signed |
907 |
2024-03-01 12:13 |
Anonymous (not verified) |
94.188.207.230 |
Bulls Eye Builders Llc |
406 E South st Mechanicsville 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. |
2024-03-01 |
Timothy Hansel |
bullseyebuildersllc@gmail.com |
Mechanicsville |
Cedar |
Iowa |
Kevin Kofron |
Jackie hart |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Timothy Hansel |
bullseyebuildersllc@gmail.com |
Owner |
Mechanicsville |
Iowa |
United States |
Kevin Kofron |
Jackie Hart |
Signed |
135 |
2020-11-20 11:05 |
Anonymous (not verified) |
208.95.1.97 |
Burds Communities Inc. |
606 S 3rd Street, Bellevue, IA 52031 |
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. |
2020-11-20 |
Todd Burds |
burdshousing@yahoo.com |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Todd Burds |
burdshousing@yahoo.com |
President |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
136 |
2020-11-20 11:06 |
Anonymous (not verified) |
208.95.1.97 |
Burds Communities Inc. |
606 S 3rd Street, Bellevue, IA 52031 |
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. |
2020-11-20 |
Tim Burds |
burdshousing@yahoo.com |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tim Burds |
burdshousing@yahoo.com |
Vice President |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
754 |
2023-08-21 17:14 |
Anonymous (not verified) |
94.188.205.177 |
Burgess Investments DBA Heartland Pest Control Inc |
PO Box 8043 Cedar Rapids, IA 52408 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-21 |
CURT BURGESS |
curtburgess73@gmail.com |
CEDAR RAPIDS |
IA |
United States |
Doug Wilson |
Michael McMeins |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CURT BURGESS |
curtburgess73@gmail.com |
Self |
CEDAR RAPIDS |
IA |
United States |
Doug Wilson |
Michael McMeins |
Signed |
944 |
2024-04-03 16:51 |
Anonymous (not verified) |
94.188.205.166 |
Butcher Insurance & Financial Services, Inc. |
220 5th Ave S Clinton, IA 52732 |
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. |
2024-04-03 |
David E Butcher |
dave.butcher.efmk@statefarm.com |
Galena |
JoDaviess |
Illinois |
Sabra Petersen |
Klark Sikkema |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Butcher |
dave.butcher.efmk@statefarm.com |
President |
Galena |
JoDaviess |
Illinois |
Sabra Petersen |
Klark Sikkema |
Signed |
365 |
2021-11-18 11:48 |
Anonymous (not verified) |
64.5.67.201 |
C & H Body Repair Inc. |
707 Lincoln Ave SE, Orange City, IA 51041 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-11-12 |
Aaron Huizenga |
ciui@orangecitycomm.net |
Orange City |
Sioux |
Iowa |
Daryl Beltman |
Lori Mars |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Aaron Huizenga |
ciui@orangecitycomm.net |
President |
Orange City |
Sioux |
Iowa |
Daryl Beltman |
Lori Mars |
Signed |
847 |
2024-01-04 21:10 |
Anonymous (not verified) |
94.188.207.227 |
C & L Construction |
721 NE 60th St, Pleasant Hill, IA 50327 |
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. |
2024-01-04 |
Jose M Sanchez Melendez |
landerosmary@gmail.com |
Pleasant Hill |
Polk |
Iowa |
Marianna Landeros |
Cheryl Martinez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jose M Sanchez Melendez |
landerosmary@gmail.com |
Self |
Pleasant Hill |
Polk |
Iowa |
Marianna Landeros |
Cheryl Martinez |
Signed |
560 |
2022-10-28 16:42 |
Anonymous (not verified) |
207.177.1.151 |
CAC Tent LLC |
2335 300th Street |
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. |
2022-10-28 |
Cory Allen Caldwell |
northiowatentandawning@gmail.com |
Ventura |
Hancock |
Iowa |
Chuck Forrest |
Ashley Kinnan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cory Caldwell |
northiowatentandawning@gmail.com |
Owner |
Ventura |
Hancock |
Iowa |
Chuck Forrest |
Ashley Kinnan |
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 |
955 |
2024-04-11 10:31 |
Anonymous (not verified) |
94.188.207.228 |
Calvillo & Son Construction |
1802 mondamin ave Des Moines 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. |
2024-04-11 |
Gerardo Calvillo |
joedhsanchez@icloud.com |
Des Moines |
Polk |
Iowa |
Agustín Téllez |
Aurora Maciel Colin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gerardo Calvillo |
joedhsanchez@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Agustín Téllez |
Aurora Maciel Colin |
Signed |
957 |
2024-04-15 10:15 |
Anonymous (not verified) |
94.188.207.226 |
Calvillo & Son Construction |
1802 Mondamin Ave, Des Moines, 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. |
(2) I decline to reject the employer’s liability coverage. |
2024-04-15 |
Gerardo Calvillo |
Joedhsanchez@icloud.com |
Des Moines |
Polk |
Iowa |
Agustín Téllez |
Aurora Maciel Colin |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Gerardo Calvillo |
Joedhsanchez@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Agustín Téllez |
Aurora Maciel Colin |
Signed |
779 |
2023-10-04 07:14 |
Anonymous (not verified) |
94.188.207.225 |
CanD Homes, LLC |
1147 Leitha Ter, Waverly, IA 50677 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-04 |
Alexander Eckard-Lewis |
alex.lewis@candhomes.com |
Waverly |
Bremer |
IA |
Connor Eustice |
Victor Sanders |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Alexander Eckard-Lewis |
alex.lewis@candhomes.com |
Vice President |
Waverly |
Bremer |
IA |
Connor Eustice |
Victor Sanders |
Signed |
694 |
2023-06-20 13:25 |
Anonymous (not verified) |
94.188.207.229 |
Canvas Products Co. |
182 Main Street Dubuque, Iowa 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. |
2023-06-20 |
Frank Salwolke |
frank@dbqcanvas.com |
Dubuque |
IA |
Iowa |
Ashley A. Trowbridge |
Taylor J. Trowbridge |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
frank salwolke |
frank@dbqcanvas.com |
President |
DUBUQUE |
IA |
Iowa |
Ashley A. Trowbridge |
Taylor J. Trowbridge |
Signed |