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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:
432 2022-03-25 15:49 Anonymous (not verified) 199.241.229.222 Ney Trucking Inc 5070 Wolff Rd Dubuque, IA 52002 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. 2022-03-25 Marvin L Ney marvin@paramountems.com Peosta Dubuque IA Brenda Weatherwax Becky Schmelzer Signed (1) The corporation rejects the employers’ liability coverage. Maria Ney maria@neytrucking.com President Peosta Dubuque IA Brenda Weatherwax Becky Schmelzer Signed
544 2022-09-27 09:00 Anonymous (not verified) 204.155.61.217 Four Guys Auto, Inc. 4705 Johnson Ave NW, Cedar Rapids, IA 52405 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. 2022-09-27 Scott Atwood office@fourguysauto.com Cedar Rapids Linn Iowa Sharon Naber Molly Feldman Signed (1) The corporation rejects the employers’ liability coverage. Scott Atwood office@fourguysauto.com President Van Horne Benton Iowa Sharon Naber Molly Feldman 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
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
880 2024-02-04 18:45 Anonymous (not verified) 94.188.205.176 One Call Exteriors 1928 9th St Des Moines IA 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. 2024-02-04 Nancy López onecallexteriors@gmail.com Des Moines Polk IA Noé Ordaz Angie Florian Signed (1) The corporation rejects the employers’ liability coverage. Nancy López onecallexteriors@gmail.com Owner Des Moines Polk IA Noé Ordaz Angie Florian Signed
975 2024-05-06 14:30 Anonymous (not verified) 94.188.207.228 Plendl Farm Mangement LLC 4951 Harrison Ave, Maurice, IA 51036 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. 2024-05-06 Christopher Plendl mcplendl@mtcnet.net Maurice Sioux IA Stacey Paulsen Austin Reitz Signed (1) The corporation rejects the employers’ liability coverage. Gerald Van Roekel gerald@veinsurance.com agent Orange City Sioux IA Stacey Paulsen Austin Reitz 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
224 2021-03-29 11:26 Anonymous (not verified) 174.198.71.64 Pro wash Dubuque inc 1795 Atlantic 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. 2021-03-28 Jordan John block prowashdubuque@gmail.com East Dubuque Jo Davis IL Abigail Ann Metcalf Dawn Marie block Signed (1) The corporation rejects the employers’ liability coverage. Ludovissy insurance jeff@ludovissyandassociates.com He is my agent Dubuque Dubuque country IA Jordan John block Abigail Ann Metcalf Signed
336 2021-09-16 18:53 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 Petr Brazdil petr.brazdil@clean.tech Trida Spojencu Brno Czechia in Europe Robbie Lemos Teresa Leibnitz Signed (1) The corporation rejects the employers’ liability coverage. Robbie Lemos robbie.lemos@clean.tech CEO SAN RAMON Contra Costa County CA Robbie Lemos Teresa Leibnitz Signed
448 2022-04-19 15:15 Anonymous (not verified) 184.80.177.137 Andrew Lemke DBA: TAP Fabrication 27214 218th Street, Earlville, IA 52041 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-04-08 Andrew Lemke jheims@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com agent Dyersville Dubuque Iowa Derrick Parsons Joyce Heims 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
672 2023-05-22 10:24 Anonymous (not verified) 94.188.205.176 Carbajal Construction Inc 888 Oxen Lane Iowa City, IA 52240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-05-22 Jesus Carbajal gina2love@gmail.com Iowa City Johnson Iowa Brad Bower Kirk Strunk Signed (1) The corporation rejects the employers’ liability coverage. Jesus Carbajal gina2love@gmail.com President Iowa City Johnson Iowa Brad Bower Kirk Strunk Signed
784 2023-10-09 13:09 Anonymous (not verified) 94.188.205.177 SEHIC G&S LLC 4201 62nd st apt 4 Urbandale Iowa 50322 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-09 Bajro Sehic kalesija20@gmail.com Urbandale Polk Iowa Bajro sehic Bajro sehic Signed (1) The corporation rejects the employers’ liability coverage. Bajro sehic kalesija20@gmail.com Owner Urbandale Polk Iowa Bajro sehic Bajro Sehic Signed
16 2019-12-12 13:17 Anonymous (not verified) 65.126.161.162 MGF Concrete DBA Michael Frandsen 3306 66th Avenue Moline, IL 61265 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. 2019-12-12 Michael Frandsen None@none.com Moline Rock Island Illinois Sarah Robertson Beth Welzenbach Signed (1) The corporation rejects the employers’ liability coverage. Michael Frandsen None@none.com Owner Moline Rock Ilsand Illinois Sarah Robertson Beth Welzenbach 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
128 2020-10-29 07:51 Anonymous (not verified) 74.84.91.178 J & J Drywall LLC 1277 Elm 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. 2020-10-27 Jeff Frick frickdbq@gmailc.com Dubuque Dubuque IA Brenda Lewis Gabe Drewelow Signed (1) The corporation rejects the employers’ liability coverage. Jeff Frick frickdbq@gmailc.com president Dubuque Dubuque Iowa Brenda Lewis Gabe Drewelow Signed
240 2021-04-16 08:30 Anonymous (not verified) 66.43.227.177 Zern Farm Corp 15109 330th St. Conrad, IA 50621 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-04-03 Cloris Zern nicole.stone@gnbins.com Conrad Grundy Iowa Nicole Stone Jeff Beeghly Signed (1) The corporation rejects the employers’ liability coverage. Cloris Zern nicole.stone@gnbins.com Secretary Conrad Grundy Iowa Nicole Stone Jeff Beeghly Signed
352 2021-10-27 12:59 Anonymous (not verified) 206.80.128.65 Employee Fringes Audit Co 710 N Buxton St, Indianola, IA 50125 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-10-27 Patrick Heller patjh@yahoo.com Indianola Warren IOWA Joseph McCollum Heather Husman Signed (1) The corporation rejects the employers’ liability coverage. Judith Heller patjh@yahoo.com Owner Indianola Warren Iowa Joseph McCollum Heather Husman Signed
464 2022-05-06 10:15 Anonymous (not verified) 172.86.44.178 Cornhill Express LLC 6472 40th St, Aurora, IA 50607 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. 2022-05-06 Jamie Fettkether sales@cherepair.com Aurora Buchanan Iowa Ben Hogan Ryan Peyton Signed (1) The corporation rejects the employers’ liability coverage. Jamie Fettkether sales@cherepair.com Owner Aurora Buchanan Iowa Ben Hogan Ryan Peyton Signed
576 2022-12-01 10:54 Anonymous (not verified) 97.125.244.8 R A Snow Removals, Inc 525 7th St NW, Altoona, IA 50009 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. 2022-12-01 Robert Aaron Snow snowelectric22@gmail.com Altoona Polk Iowa Shannon Keely Moses Jameson Robert Snow Signed (1) The corporation rejects the employers’ liability coverage. Robert Aaron Snow snowelectric22@gmail.com Owner Altoona Polk Iowa Shannon Keely Moses Jameson Robert Snow Signed
688 2023-06-16 08:08 Anonymous (not verified) 94.188.205.169 Ezequiel Campos Rojas 2910 50th Street Des Moines, Iowa 50310 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. 2023-06-16 Ezequiel Campos Rojas Zequiel.11campos@gmail.com Des Moines Polk Iowa Daysi Campos Gaytan Rosalba Soto Hernandez Signed (1) The corporation rejects the employers’ liability coverage. Ezequiel Campos Rojas Zequiel.11campos@gmail.com Owner Des Moines Polk Iowa Daysi Campos Gaytan Rosalba Soto Hernandez Signed
800 2023-10-23 07:40 Anonymous (not verified) 94.188.207.228 Lucas construction inc 1707 mondamin ave des moines , Iowa I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-10-23 Luis Arturo Martinez Lucas luiss_95@icloud.com Des Moines USA Iowa Cristian António Martínez Lucas Manuel canizales Signed (1) The corporation rejects the employers’ liability coverage. Luis Arturo Martinez Lucas luiss_95@icloud.com President Des Moines Usa Iowa Cristian António Martínez Lucas Manuel canizales Signed
895 2024-02-23 14:59 Anonymous (not verified) 94.188.205.169 Pas Construction LLC. 1125 Hubbard Ave Ne. Cedar rapids 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. 2024-02-23 Steven M. Helle helle4513@gmail.com Fairfax Linn Iowa Claudia Venable Matthew Himmel Signed (1) The corporation rejects the employers’ liability coverage. Steven Helle helle4513@gmail.com Owner Fairfax Linn Iowa Claudia Venable Matthew Himmel Signed
32 2020-01-14 10:33 Anonymous (not verified) 108.171.132.189 B & C Lawn Care Inc P.O. Box 55, Boone, IA 50036 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-01-01 Travis Garrett onethird4599@gmail.com Boone Boone Iowa Katie Frame Jessica Carroll Signed (1) The corporation rejects the employers’ liability coverage. Travis Garrett onethird4599@gmail.com Owner Boone Boone IOWA Katie Frame Jessica Carroll Signed
144 2020-12-04 12:02 Anonymous (not verified) 184.80.177.137 Arlen, LLC 322 6th St SE - Dyersville, Iowa 52040 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. 2020-12-04 Dan Arlen jheims@english-insurance.com Dyersville IA IA Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Joyce Heims joyce.heims1@gmail.com agent Dyersville IA IA Derrick Parsons Joyce Heims Signed
256 2021-05-05 08:04 Anonymous (not verified) 206.127.178.33 NSense, Inc. 415 Stanton Ave Suite 205, Ames, IA 50014 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-05-05 Stephen R Ringlee sringlee@n-sense.us Ames Story Iowa Constance J. Ringlee Robert Anders Signed (1) The corporation rejects the employers’ liability coverage. Stephen R Ringlee sringlee@n-sense.us Director Ames Story Iowa Constance J Ringlee Robert Anders Signed
368 2021-11-24 07:11 Anonymous (not verified) 173.20.97.32 Neppl Landscape Architecture and Planning, LLC 3013 Briggs Circle Ames, Iowa 50010 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. 2021-11-24 Thomas George Neppl tom@tomneppl.com Ames Story Iowa Ashlyn Kay Neppl Tricia Kay Neppl Signed (1) The corporation rejects the employers’ liability coverage. Thomas George Neppl tom@tomneppl.com Owner Ames Story Iowa Ashlyn Kay Neppl Tricia Kay Neppl Signed
480 2022-05-30 11:37 Anonymous (not verified) 134.215.6.237 Access Property Management Corp DBA Wine & Spirits 510 E Carrington Ln, Appleton, WI 54913 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. 2022-05-30 Lisa M Ricklefs lisarick19@yahoo.com Appleton Outagamie WI Jeff Fonferek Melissa Fonferek Signed (1) The corporation rejects the employers’ liability coverage. Thomas Ricklefs tjrick@yahoo.com President Appleton Outagamie WI Jeff Fonferek Melissa Fonferak Signed
592 2023-01-22 11:29 Anonymous (not verified) 216.106.211.176 Trackside Service & Repair Inc. 205 Main St. Alvord, IA 51230 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. 2022-01-22 Renee J Klarenbeek dkranch@alliancecom.net Rock Rapids Iowa United States Steve C. Green Darwyn G. Klarenbeek Signed (1) The corporation rejects the employers’ liability coverage. Darwyn G. Klarenbeek trackside@alliancecom.net Owner Rock Rapids Lyon IA Steve C. Green Darwyn G. Klarenbeek Signed
704 2023-06-30 11:09 Anonymous (not verified) 94.188.205.174 KLS Meter Services, LLC 1000 Woodbury Council Bluffs IA 51503 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-06-29 Kevin Schrage kls2021@yahoo.com Council Bluffs Pottawattamie IA Stephan Nelson Miriam Martinez Signed (1) The corporation rejects the employers’ liability coverage. David E Pike Stephan@pikeinsuranceservices.com Broker Oceanside California CA Stephan Nelson Miriam Martinez Signed
816 2023-11-15 15:22 Anonymous (not verified) 94.188.205.166 MO VALLEY TACO INC 1971 LINCOLN HWY MISSOURI VALLEY IA 51555 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. 2023-11-01 MARTIN ALVAREZ abelardosmexicanfresh7@gmail.com MISSOURI VALLEY HARRISON IA GONZALO MUNOZ SILVIA CHAVEZ Signed (1) The corporation rejects the employers’ liability coverage. MARTIN ALVAREZ abelardosmexicanfresh7@gmail.com OWNER MISSOURI VALLEY HARRISON IA GONZALO MUNOZ SILVIA CHAVEZ Signed
911 2024-03-02 14:34 Anonymous (not verified) 94.188.205.168 Gerlich Enterprises 2824 Hickory Hills Ln 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. 2024-03-02 Garrett Gerlich paul@gerlich.io Bettendorf scott IA Paul Gerlich Kelsey Gerlich Signed (1) The corporation rejects the employers’ liability coverage. Paul Gerlich paul@gelrich.io Owner Bettendorf Scott Iowa Kelsey Gerlich Elora Gerlich Signed
48 2020-03-18 09:58 Anonymous (not verified) 67.22.192.111 Rozeboom Trucking Inc. PO Box 110 Sioux Center IA 51250 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-18 Kirk Hulstein kirkh@barkcattle.com Sioux Center Sioux Iowa Linda Kieft Tiffany Govig Signed (1) The corporation rejects the employers’ liability coverage. Kirk Hulstein kirkh@barkcattle.com president Sioux Center Sioux Iowa Linda Kieft Tiffany Govig Signed
160 2021-01-13 10:52 Anonymous (not verified) 173.190.64.239 united workers inc 711 4th st ne I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-13 mayra sapolvada buck@trvnet.net Belmond wright iowa shannon muhlenbruch Martha Leal Signed (1) The corporation rejects the employers’ liability coverage. mayra sapulvada buck@trvnet.net president belmond wright ia shannon myhlenbruch martha leal Signed
605 2023-02-17 11:29 Anonymous (not verified) 94.188.207.223 McDonald Construction 617 Kingsley Ave, Waterloo 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. 2022-02-17 Todd Gelner toddandabbey@yahoo.com Denver Bremer Iowa Abbey Gelner Abbey Elizabeth-Anne Gelner Signed (1) The corporation rejects the employers’ liability coverage. Todd Gelner toddandabbey@yahoo.com Self Denver Bremer Iowa Abbey Gelner Karen Henry Signed
717 2023-07-26 11:31 Anonymous (not verified) 94.188.207.230 Lampe Appliance Service, Inc 210 29th St NE, Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-07-26 Jared Joshua Lampe lampeappliance@gmail.com CEDAR RAPIDS Linn Iowa Douglas James Lampe John Kenneth Lampe Signed (1) The corporation rejects the employers’ liability coverage. Douglas James Lampe lampeappliance@gmail.com President CEDAR RAPIDS Linn United States John Kenneth Lampe Jared Joshua Lampe Signed
829 2023-11-27 08:59 Anonymous (not verified) 94.188.207.224 Adam Ruess Masonry 206.w Elm 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. 2023-11-27 Adam Ruess ruess33@gmail.com Lone Tree IA United States Adam Ruess Adam Ruess Signed (1) The corporation rejects the employers’ liability coverage. Adam Ruess ruess33@gmail.com Owner Lone Tree IA United States Adam Ruess Adam Ruess 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
61 2020-04-20 13:13 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-01 Bruce Tamisiea jennifer@walkerinsuranceia.com Wahpeton Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Bruce Tamisiea jennifer@walkerinsuranceia.com Board Member Wahpeton Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
173 2021-01-26 19:29 Anonymous (not verified) 173.17.84.174 Robert Schroeder const. inc 10984 150 th. st. davenport ia. 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-26 ROBERT SCHROEDER r.schroeder@aol.com davenport scott ia. Debra Blaser John Ekin Signed (1) The corporation rejects the employers’ liability coverage. ROBERT SCHROEDER r.schroeder@aol.com President davenport scott ia. Debra Blaser John Ekin Signed
285 2021-06-30 14:33 Anonymous (not verified) 75.162.212.130 Superior Painting and Remodeling, corp 8415 Franklin Ave Apt 49 Clive, Iowa 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-06-30 Luz Maria Morales Gutierrez lm3673719@gmail.com Des Moines United State Iowa Liliana Sanchez Yolanda Mendoza Signed (2) The corporation declines to reject the employers’ liability coverage. Superior Painting and Remodeling Corp lm3673719@gmail.com Owner Des Moines United State Iowa Liliana Sanchez Yolanda Mendoza Signed
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
509 2022-07-05 13:51 Anonymous (not verified) 96.31.7.128 KROESE CONSTRUSTION INC. 822 7TH 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. 2022-06-06 DAVID A KROESE dkkroese@hotmail.com Hull Sioux Iowa MATTHEW ROETMAN JOYCE VANDER WELL Signed (1) The corporation rejects the employers’ liability coverage. SCOTT I KROESE scottkroese@hotmail.com vice president HULL SIOUX IOWA MATTHEW ROETMAN JOYCE VANDER WELL Signed
621 2023-03-08 07:53 Anonymous (not verified) 94.188.207.223 Don Wyckoff Heating Inc. 95 Highway 5, Carlisle, IA 50047 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-04 Michael T Johnson mikeyjay1968@gmail.com Des Moines Polk IA Brady Cooper Carey Cooper Signed (1) The corporation rejects the employers’ liability coverage. Mike Johnson mikeyjay@gmail.com Sub-Contractor Des Moines Polk IA Brady Cooper Carey Cooper Signed
733 2023-08-09 10:22 Anonymous (not verified) 94.188.207.230 Atcher Service LLC 145 Fremont Street, Hartford, IA 50118 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-08 Daniel J Love atcherservicetowing@gmail.com Hartford Warren Iowa Mandy Love Michael Love Signed (1) The corporation rejects the employers’ liability coverage. Mandy Love dlovem2002@gmail.com owner Hartford Warren Iowa Dan Love Michael Love Signed
845 2024-01-02 09:03 Anonymous (not verified) 94.188.205.169 American Tree Service LLC 416 S Kiel Street, Holstein, IA 51025 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. 2024-01-02 Austin Thevenot americantreeservice03@gmail.com Holstein Ida Iowa Jared Brashears Katie Gunkelman Signed (1) The corporation rejects the employers’ liability coverage. Austin Thevenot americantreeservice03@gmail.com Owner Holstein Ida Iowa Jared Brashears Katie Gunkelman Signed
940 2024-04-03 07:49 Anonymous (not verified) 94.188.205.167 Wildride Trucking 3261 old river rd sw. Cedar Rapids 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. 2024-04-03 David mckee wildride1969@gmail.com Cedar Rapids Lynn Ia Valerie mckee Dillon Williams Signed (1) The corporation rejects the employers’ liability coverage. Dave mckee wildride1969@gmail.com Owner Cedar Rapids Lynn Ia Valerie mckee Dillon Williams Signed
77 2020-05-05 16:47 Anonymous (not verified) 173.21.16.121 Kevan Oliver Trim Carpentry, Inc. 2900 Scott Park Road, Eldridge, IA 52748 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. 2020-05-05 Kevan Oliver kkoliverinc@gmail.com Eldridge Scott Iowa Franco Muñoz Rolando Muñoz Signed (2) The corporation declines to reject the employers’ liability coverage. Kevan Oliver kkoliverinc@gmail.com President Eldridge Scott Iowa Franco Muñoz Rolando Muñoz Signed
189 2021-02-25 10:56 Anonymous (not verified) 173.27.130.150 Southside Boat Club Post Office Box 674, Keokuk, Iowa 52632 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-01 Kathryn L. Farris southsideboatclub@gmail.com Hamilton Illinois United States Roger D. Huston Janis Leann Wallingford Signed (1) The corporation rejects the employers’ liability coverage. Jeri Denise Asbridge Kerryasbridge1@mediacombb.net Treasurer Hamilton Illinois United States Roger D. Huston Janis Leann Wallingford Signed
301 2021-08-04 10:05 Anonymous (not verified) 63.142.48.170 Vision Homes Inc 2566 Ivanhoe Rd. 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. 2021-07-02 DeeAnn Nejdl chucknejdl@gmail.com Cedar Rapids Linn Iowa Melanie Heitman Dan Lillis Signed (1) The corporation rejects the employers’ liability coverage. DeeAnn Nejdl chucknejdl@gmail.com Owner Cedar Rapids Linn Iowa Melanie Heitman Dan Lillis Signed