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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:
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
370 2021-12-07 10:08 Anonymous (not verified) 208.126.71.193 Ryco Customs, Inc. 2920 4th Ave S., Clear Lake, IA 50428 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. 2021-12-07 Ryan Ruter ryan@rycocustoms.com Clear Lake Cerro Gordo Iowa Kimberly M Martin Taylor Weiland Signed (1) The corporation rejects the employers’ liability coverage. Ryan Ruter ryan@rycocustoms.com Owner Clear Lake Cerro Gordo Iowa Kimberly M Martin Taylor Weiland Signed
397 2022-02-01 10:30 Anonymous (not verified) 159.242.43.24 Providence Casework PO Box 205 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. 2022-01-01 Neal Keeling office@procaseworks.com Rockwell Cerro Gordo Iowa Josh Olson John Moran Signed (1) The corporation rejects the employers’ liability coverage. Neal Keeling office@procaseworks.com Owner Rockwell Cerro Gordo Iowa Josh Olson John Moran Signed
759 2023-08-31 16:11 Anonymous (not verified) 94.188.207.230 Living Free Ministries 11 2nd St NW, Mason City, IA 50401 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. 2023-08-31 Jani Dahlin livingfreeiowa@gmail.com Mason City Cerro Gordo IA Jenny McIntyre Alex Meier Signed (1) The corporation rejects the employers’ liability coverage. Jani Dahlin livingfreeiowa@gmail.com President Mason City Cerro Gordo IA Jenny McIntyre Alex Meier Signed
790 2023-10-17 14:16 Anonymous (not verified) 94.188.205.166 Reform exteriors 326 1st street mason city IA I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-16 Manuel g ramos ramosm943@gmail.com IA Cerro gordo Iowa Manuel ramos Manuel ramos Signed (1) The corporation rejects the employers’ liability coverage. Manuel g ramos ramosm943@gmail.com Owner Iowa Cerro gordo Iowa Manuel ramos Manuel ramos Signed
391 2022-01-26 16:08 Anonymous (not verified) 207.199.212.86 Geerts Plumbing and Heating Inc. 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. 2021-07-07 Adam S Geerts lacy@cioia.com New Hampton Chickasaw Iowa Lacy Carolan Maddi Moorman Signed (1) The corporation rejects the employers’ liability coverage. Adam S Geerts lacy@cioia.com Owner New Hampton Chickasaw Iowa Lacy Carolan Maddi Moorman 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
865 2024-01-23 14:32 Anonymous (not verified) 94.188.205.177 Josh Oswald 505 Eisenhower Rd., Osceola, IA 50213 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. 2024-01-23 Joshua Oswald jjoswald47@gmail.com Osceola Clarke Iowa Douglas Eugene Miller Elaine Lee Signed (1) The corporation rejects the employers’ liability coverage. Joshua Oswald jjoswald47@gmail.com Owner/Sole Proprietor Osceola Clarke Iowa Douglas Eugene Miller Elaine Lee Signed
37 2020-02-06 15:49 Anonymous (not verified) 100.42.95.100 Matthew Saboe 2075 330th 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. 2020-02-06 Matthew Saboe galmgirl@gmail.com Spencer Clay IA Laura Ashley Tauscher Diane Kimball Signed (1) The corporation rejects the employers’ liability coverage. Matthew Saboe galmgirl@gmail.com Owner Spencer Clay IA Laura Ashley Tauscher Diane Kimball Signed
60 2020-04-20 13:06 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, PO 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 Charley Whittenburg jennifer@walkerinsuranceia.com Spencer Clay Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Charley Whittenburg jennifer@walkerinsuranceia.com Vice President Spencer Clay Iowa Joseph Thomas Loring Jennifer Janet Youngwirth 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
393 2022-01-26 16:35 Anonymous (not verified) 216.51.137.244 Metal Works, Inc. 1015 32nd Ave W, 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. 2022-01-01 Ben Nystrom ffernandez@thamsagency.com Spencer Clay Iowa Phil Ramstack Francia Fernandez Signed (1) The corporation rejects the employers’ liability coverage. Ben Nystrom ffernandez@thamsagency.com Owner Spencer Clay Iowa Philp Ramstack Francia Fernandez Signed
991 2024-05-16 11:50 Anonymous (not verified) 94.188.207.229 NSG, LLC 2935 Highway 18, Dickens, IA 51333 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. 2024-05-16 Rosemary G Norgaard rosemary@norgaardllc.com Dickens Clay United States Dan Claus Ange Claus Signed (1) The corporation rejects the employers’ liability coverage. Rosemary G Norgaard rosemary@norgaardllc.com MEMBER Dickens Clay United States Dan Claus Ange Claus Signed
175 2021-02-01 11:20 Anonymous (not verified) 216.51.132.207 VONDERHAAR CONSTRUCTION 33181 OSTERDOCK RD GUTTENBERG IA 52052 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. 2020-12-28 ROBIE VONDERHAAR nicole@cioia.com GUTTENBERG CLAYTON IA JERRY J ROCHFORD NICOLE L PARKER Signed (1) The corporation rejects the employers’ liability coverage. ROBIE VONDERHAAR NICOLE@CIOIA.COM OWNER Guttenberg CLAYTON IA JERRY J ROCHFORD NICOLE L PARKER Signed
396 2022-02-01 10:03 Anonymous (not verified) 184.80.177.137 LKB Holdings, LLC P.O. box 313 - Monona, Ia 52159 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. 2022-01-29 Kandi Gillitzer jheims@english-insurance.com Monoa Clayton Iowa Joyce Heims Derrick Parsons Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com self Dyersville Dubuque Iowa Derrick Parsons Joyce Heims 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
676 2023-05-26 16:16 Anonymous (not verified) 94.188.207.230 Miller Lawn Care LLC 1323 S Hwy 52 Guttenberg IA 52052 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-26 Steven Miller nicole@cioia.com Guttenberg Clayton IA Nicole Parker Jerry J Rochford Signed (1) The corporation rejects the employers’ liability coverage. Steven Miller nicole@cioia.com owner-self Guttenberg Clayton IA Nicole Parker Jerry J Rochford Signed
38 2020-02-08 13:16 Anonymous (not verified) 208.126.52.97 Savage Industries Inc 2368 110th street Delmar, ia 52037 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-02-08 Jordan Hicks jjjhicks22@gmail.com Delmar Clinton Iowa Brittany Hicks Alex Laban Signed (1) The corporation rejects the employers’ liability coverage. Jordan Hicks jjjhicks22@gmail.com President Delmar Clinton Iowa Brittany Hicks Alex Laban Signed
138 2020-11-24 14:11 Anonymous (not verified) 173.215.17.41 Dohrmann Enterprises, Inc 2478 260th Ave. DeWitt, Iowa 52742 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. 2020-11-24 Joel Dohrmann dohrmannpnh@gmail.com DE WITT Clinton IA Susanne Owen Daron Oberbroecking Signed (1) The corporation rejects the employers’ liability coverage. Susanne Owen sowen@ohnward.com none Camanche Clinton Iowa Joel Dohrmann Daron Oberbroecking Signed
145 2020-12-18 07:54 Anonymous (not verified) 173.215.16.15 Dohrmann Enterprises Inc 2652 350th Ave DeWitt, IA 52742 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. 2020-12-18 Tom Dohrmann dohrmannpnh@gmail.com DeWitt Clinton Iowa Susanne Owen Daron Oberbroeckling Signed (1) The corporation rejects the employers’ liability coverage. Tom Dohrmann dohrmannpnh@gmail.com Owner DeWitt Clinton Iowa Susanne Owen Daron Oberbroeckling Signed
418 2022-03-03 14:29 Anonymous (not verified) 72.255.79.18 Ostafi Communication Inc. 2121 Swan Dr. Camanche, IA 52730 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 Eduard Ostafi ostaficommunication@gmail.com Camanche Clinton IA Stephanie Millage Amanda Van Theemsche Signed (1) The corporation rejects the employers’ liability coverage. Eduard Ostafi ostaficommunication@gmail.com President Camanche Clinton IA Stephanie Millage Amanda Van Theemsche Signed
425 2022-03-16 07:57 Anonymous (not verified) 173.29.149.199 Schult Industries Inc PO Box 165 Camanche, IA 52730 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. 2022-03-17 MIKE SCHULT mschult10@gmail.com CLINTON Clinton Iowa Rhonda Schult Lance VanDeest Signed (1) The corporation rejects the employers’ liability coverage. MIKE SCHULT mschult10@gmail.com Owner CLINTON Clinton Iowa Rhonda Schult Lance VanDeest Signed
247 2021-04-27 09:35 Anonymous (not verified) 207.191.206.210 United windows and siding 4080 1st Avenue NE, Cedar Rapids Iowa 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2021-04-27 Adrian Sanchez adrian@unitedwindowsandsiding.com Aurora CO United States Megan Bierley Ginger Berens Signed (2) The corporation declines to reject the employers’ liability coverage. Adrian Sanchez adrian@unitedwindowsandsiding.com Owner Aurora Jeffereson CO Megan Bierley Ginger Berens Signed
335 2021-09-16 17:22 Anonymous (not verified) 64.142.5.50 Electrious Inc DBA Clean Tech 1110 Alhambra Ave Martinez CA 94533. 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. 2021-08-26 Robert Lemos robbie.lemos@clean.tech San Ramon Contra Costa County CA Teresa Leibnitz Greg Vermeulen Signed (1) The corporation rejects the employers’ liability coverage. Robbie Lemos robbie.lemos@clean.tech CEO San Ramon Contra Costa County CA Teresa Leibnitz Greg Vermeulen Signed
333 2021-09-14 14:53 Anonymous (not verified) 147.0.156.50 O'Danny Boy Builders, Inc. 7512 S. County Line Rd., Suite #4, Burr Ridge, IL 60527 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-09-14 Daniel Flanagan jflanagan@odannyboybuilders.com LaGrange Cook Illinois John Flanagan Mark Hayes Signed (1) The corporation rejects the employers’ liability coverage. John Flanagan Jflanagan@odannyboybuilders.com Executive Western Springs Cook IL Ben Weed Mark Hayes Signed
460 2022-05-02 10:00 Anonymous (not verified) 73.9.3.194 ERLIN AVILA INC 1940 N GREEN LN APT 2A PALATINE IL 60074 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. 2022-05-02 ERLIN AVILA INC dianalcandelaria@aol.com PALATINE COOK IL DIANA CANCELARIA DALILA VILLEGAS Signed (1) The corporation rejects the employers’ liability coverage. ERLIN AVILA TORREZ dianalcandelaria@aol.com PRESIDENT PALATINE Illinois United States Diana L Candelaria DALILA VILLEGAS Signed
978 2024-05-08 13:47 Anonymous (not verified) 94.188.205.174 Meridian Logistics, LLC 5249 N Park Pl NE, Unit #2060, Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-07 Abigail Matthews almsolutions2021@gmail.com Chicago Cook IL Gayle Matteson Jane Calvert Signed (2) The corporation declines to reject the employers’ liability coverage. Abigail Matthews almsolutions2021@gmail.com Owner Chicago Cook IL Gayle Matteson Jane Calvert Signed
152 2021-01-04 12:08 Anonymous (not verified) 104.129.206.120 Schleswig Transfer Inc 216 Valley View Dr, Schleswig, IA 51461 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. 2020-11-30 Wade Miller t.uhl3@joemorten.com Schleswig Crawford Iowa Tamara Uhl Amy Meseck Signed (1) The corporation rejects the employers’ liability coverage. Wade Miller t.uhl3@joemorten.com President Schleswig Crawford IA Tamara Uhl Amy Meseck Signed
589 2023-01-16 10:18 Anonymous (not verified) 174.130.20.253 HCS Trucking LLC 403 Date St Schleswig, IA 51461 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. 2023-01-16 Jamie Hedstrom hedstromcrane@gmail.com Schleswig Crawford Iowa Noah Hedstrom Landa Hedstrom Signed (2) The corporation declines to reject the employers’ liability coverage. Jamie Hedstrom hedstromcrane@gmail.com owner Schleswig Crawford Iowa Noah Hedstrom Landa Hedstrom Signed
211 2021-03-25 09:10 Anonymous (not verified) 204.155.61.217 The New Leaf Co 1095 Oakdale Ave, St Paul, MN 55118 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. 2021-03-02 Michael Hernandaz liveabovethecloudz@gmail.com St Paul Dakota MN DocuSign Ashley Kraft Signed (1) The corporation rejects the employers’ liability coverage. Michael Hernandaz liveabovethecloudz@gmail.com Ower St Paul Dakota mn DocuSign Ashley Kraft Signed
646 2023-03-31 13:58 Anonymous (not verified) 94.188.205.168 American Residential Services Inc 1683 Elizabeth Dr Marion IA 52302 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-31 Robert Rettmann americanres@yahoo.com Apple Valley Dakota MN Nancy Rettmann William Dilts Signed (1) The corporation rejects the employers’ liability coverage. Robert Rettmann americanres@yahoo.com President Apple Valley Dakota MN Nancy Rettmann William Dilts Signed
583 2022-12-09 11:29 Anonymous (not verified) 74.84.79.78 Captain Kirk Construction 202 W Guthrie St. Linden, IA 50146 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. 2022-01-01 William Kirj iicaptainkirk@gmail.com Linden Dalas Iowa Michael O'Conner Ron Rand Signed (1) The corporation rejects the employers’ liability coverage. William Kirk iicaptainkirk@gmail.com Owner Linden Dallas IA Michael O'Conner Casey Kirk Signed
24 2020-01-02 09:12 Anonymous (not verified) 207.191.194.182 Waukee CabinetWorks LLC 70 SE Laurel St, Waukee IA 50263 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. 2019-12-23 Amy Balm chris.rappe@waukeecabinetworks.com Waukee Dallas Iowa Chris Andrews Dave Creighton Sr Signed (1) The corporation rejects the employers’ liability coverage. Chris Rappe chris.rappe@waukeecabinetworks.com Operations Manager Waukee Dallas IA Chris Andrews Dave Creighton SR Signed
25 2020-01-02 09:17 Anonymous (not verified) 207.191.194.182 Waukee CabinetWorks LLC 70 SE Laurel St, Waukee IA 50263 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. 2019-12-23 Jason Balm chris.rappe@waukeecabinetworks.com Waukee Dallas Iowa Chris Andrews Dave Creighton Sr Signed (1) The corporation rejects the employers’ liability coverage. Chris Rappe chris.rappe@waukeecabinetworks.com Operations Manager Waukee Dallas Iowa Chris Andrews Dave Creighton SR Signed
97 2020-07-09 10:07 Anonymous (not verified) 173.215.13.54 LOS DOS MEXICAN RESTAURANT DBA CASA DE ORO 1211 2ND ST, PERRY IOWA 50220 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 MARIO LEPE DAVID.FINNESETH@FBFS.COM PERRY DALLAS IOWA ROBERTA L GILSON SANDRA S WHEELER Signed (1) The corporation rejects the employers’ liability coverage. MARIO LEPE DAVID.FINNESETH@FBFS.COM VICE PRESIDENT PERRY DALLAS IOWA ROBERTA L GILSON SANDRA S WHEELER 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
462 2022-05-02 16:01 Anonymous (not verified) 71.39.227.238 IN SEASON LAWN CARE LLC 32841 HOMESTEAD DR, GRANGER, IA 50109 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. 2022-05-02 JOSEPH CRAIG COVER inseason98@gmail.com Granger Dallas Iowa Abbey Luellen Steve Phillips Signed (1) The corporation rejects the employers’ liability coverage. Joseph Craig Cover inseason98@gmail.com Owner Granger Dallas Iowa Abbey Luellen Steve Phillips Signed
463 2022-05-02 16:02 Anonymous (not verified) 71.39.227.238 IN SEASON LAWN CARE LLC 32841 HOMESTEAD DR, GRANGER, IA 50109 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. 2022-05-02 CHEYENNE COVER inseason98@gmail.com Granger Dallas Iowa Abbey Luellen Steve Phillips Signed (1) The corporation rejects the employers’ liability coverage. CHEYENNE Cover inseason98@gmail.com Owner Granger Dallas Iowa Abbey Luellen Steve Phillips Signed
468 2022-05-12 11:33 Anonymous (not verified) 173.23.25.243 RS Remodelers 2863 104th St Urbandale 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. (2) I decline to reject the employer’s liability coverage. 2022-05-12 Robert Nevitt rwnevitt@yahoo.com PERRY DALLAS IA Steve Dillon Jordan Nevitt Signed (2) The corporation declines to reject the employers’ liability coverage. Robert Nevitt clearchoicedesmoinesia@gmail.com Owner Urbandale Dallas ia Steve Dillon Jordan Nevitt Signed
469 2022-05-12 11:38 Anonymous (not verified) 173.23.25.243 RS- Remodelers 2863 104th St Urbandale 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. (2) I decline to reject the employer’s liability coverage. 2022-05-12 Stephen Dillon clearchoicedesmoinesia@gmail.com Waukee Dallas IA Rob Nevitt Jordan Nevitt Signed (2) The corporation declines to reject the employers’ liability coverage. Stephen clearchoicedesmoinesia@gmail.com Owner Waukee Dallas IA Rob Nevitt Jordan Nevitt Signed
510 2022-07-12 09:13 Anonymous (not verified) 174.198.70.141 Premiere Painting, LLC 865 NE Bobcat Dr Waukee, IA. 50263 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. 2022-07-12 Scott McVay scottkmcvay@live.com Waukee Dallas Iowa Robert Ferguson Christina Pham Signed (1) The corporation rejects the employers’ liability coverage. Scott McVay scottkmcvay@live.con Owner Waukee Dallas Iowa Robert Ferguson Christina Pham Signed
538 2022-09-21 17:04 Anonymous (not verified) 174.198.67.151 Premiere Painting, LLC 865 NE Bobcat 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. 2022-09-21 Scott McVay premierepainting515@gmail.com Waukee Dallas Iowa Christina Pham Robert Ferguson Signed (1) The corporation rejects the employers’ liability coverage. Scott McVay premierepainting515@gmail.com Owner Waukee Dallas Iowa Christina Pham Robert Ferguson Signed
617 2023-03-02 18:39 Anonymous (not verified) 94.188.205.167 Fosters woodworking and design llc 26498 g ave, adel ia 50003 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. 2023-03-02 Nicholas Foster nick@fosterswooddesign.com Adel Dallas Iowa Tanya Foster Mike Merrick Signed (1) The corporation rejects the employers’ liability coverage. Nicholas Foster nfoster1988@icloud.com Owner Adel Dallas Iowa Tanya foster Mike merrick Signed
635 2023-03-23 15:43 Anonymous (not verified) 94.188.207.228 Pacifica Health Services, LLC 4911 SW 19th 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. 2023-03-23 Kevin Babb kbabb@viahealthservices.com Waukee Dallas Iowa Jackie Hastings Amber Perdue Signed (1) The corporation rejects the employers’ liability coverage. Jennifer Conner jconner@viahealthservices.com President Des Moines Polk IA Jackie Hastings Amber Perdue Signed
669 2023-05-15 09:26 Anonymous (not verified) 94.188.207.229 SOUTHWEST IOWA ELECTRIC LLC 800 NW SPRUCE ST,EARLHAM, IA 50072 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-12 ISAAC NORTON NORTON2412@GMAIL.COM EARLHAM DALLAS IOWA GARRETT ROBINSON ADDILIE NORTON Signed (1) The corporation rejects the employers’ liability coverage. ISAAC NORTON NORTON2412@GMAIL.COM PRESIDENT EARLHAM DALLAS IOWA GARRETT ROBINSON ADDILIE NORTON Signed
760 2023-09-01 08:43 Anonymous (not verified) 94.188.207.226 Paradigm Group, LLC 3263 Cumming Road, Cumming, IA 50061 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-09-01 Conor Davis conor@cdavisflooring.com Urbandale Dallas Iowa Jered Holker Wes Duncan Signed (1) The corporation rejects the employers’ liability coverage. Ryan Shabino ryan@prdgmgroup.com Owner Cumming Madison Iowa Wes Duncan Jered Holker Signed
775 2023-10-01 10:35 Anonymous (not verified) 94.188.205.169 Prem Krishnan Menon Mohan Kumar 460 NW Gracewood Dr, Waukee, IA 50263 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. 2023-10-01 Prem Krishnan Menon Mohan Kumar premkrishnan@gmail.com Waukee Dallas Iowa Dileep Vasudevan Roy Shashidharan Signed (1) The corporation rejects the employers’ liability coverage. Prem Krishnan Menon Mohan Kumar premkrishnan@gmail.com Owner Waukee Dallas Iowa Dileep Vasudevan Roy Shashidharan Signed
780 2023-10-04 16:18 Anonymous (not verified) 94.188.207.228 Premier Staffing Agency 6887 Dakota drive West Desmoines Iowa 50266 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. 2023-10-10 Felistas Kimani mwangifelistas4@gmail.com West Desmoines Dallas Iowa Denis Waweru George Komu Signed (1) The corporation rejects the employers’ liability coverage. Felistas Kimani mwangifelistas4@gmail.com member West Desmoines Dallas Iowa Denis Waweru George Komu Signed
827 2023-11-22 10:30 Anonymous (not verified) 94.188.205.169 T&R Drywall LLC 1450 NE 69th Pl Ste 56 Ankeny, IA 50021 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-11-22 Roberto Javier Rodriguez Perez Special.t.d@hotmail.com Waukee Dallas IA Omar L Tippetts Omar L Tippetts Jr Signed (1) The corporation rejects the employers’ liability coverage. N/A special.t.d@hotmail.com N/A N/A N/A N/A N/A N/A Signed