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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:
834 2023-12-13 08:35 Anonymous (not verified) 94.188.207.228 PHOENIX CONSTRUCTION LLC 2219 E 13TH ST DES MOINES, IA 50316 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-13 JUAN PABLO GUTIERREZ LEON jpgutierrez9000@yahoo.com DES MOINES IA IA DAISY VASQUEZ GRACIELA RODRIGUEZ Signed (1) The corporation rejects the employers’ liability coverage. ARTURO SALGADO commercial@aksinsurance.com Insured Irving TX TX DAISY VASQUEZ GRACIELA RODRIGUEZ Signed
840 2023-12-18 16:21 Anonymous (not verified) 94.188.205.166 DC Painting Inc 205 Astor St I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-18 Damion Clement amanda_thompson_marie@yahoo.com Des Moines polk IA Brandi Haight Amanda Thompson Signed (1) The corporation rejects the employers’ liability coverage. Damion Clement amanda_thompson_marie@yahoo.com owner Des Moines Polk IA Brandi Haight Amanda Thompson Signed
841 2023-12-18 16:28 Anonymous (not verified) 94.188.205.168 Dennis Clement 203 Astor St I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-18 Dennis Clement haight0929@gmail.com Des Moines Polk IA Amanda Thompson Brandi Haight Signed (1) The corporation rejects the employers’ liability coverage. Dennis Clement haight0929@gmail.com none Des Moines polk IA Brandi Haight Amanda Thompson Signed
842 2023-12-18 16:31 Anonymous (not verified) 94.188.205.168 Brandon Clement 3503 South Union St I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-18 Brandon Clement hawthornhill@paramark.us Des Moines Polk IA Brandi Haight Amanda Thompson Signed (1) The corporation rejects the employers’ liability coverage. Brandon Clement hawthornhill@paramark.us none Des Moines polk IA Brandi Haight Amanda Thompson Signed
846 2024-01-03 14:13 Anonymous (not verified) 94.188.205.168 Madison County Renovations Inc PO Box 521, Winterset, IA 50273 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. 2024-01-03 Jonathan Hays 17jhays@gmail.com Waukee Dallas IA Rachel Anderson Roger Queck Signed (1) The corporation rejects the employers’ liability coverage. Mark Hays mark.hays88@yahoo.com President Winterset Madison Iowa Rachel Anderson Roger Qyeck Signed
863 2024-01-23 13:59 Anonymous (not verified) 94.188.205.176 United Marble & Tile, Inc. 915 8th Street, #201, 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. 2024-01-24 Albert James Gotta jim@umtile.com Slater Boone IA Antonina M Gotta MARY KATE RUSSELL Signed (1) The corporation rejects the employers’ liability coverage. Albert James Gotta jim@umtile.com President Sole Share Holder Boone IA IA Antonina M Gotta Antonina M Gotta Signed
867 2024-01-24 15:04 Anonymous (not verified) 94.188.207.227 Shook Handyman 2415 Plum Creek Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-24 Nolan Shook office@shookhandyman.com Sioux City Woodbury IA McKenna Warner Jessica Shook Signed (1) The corporation rejects the employers’ liability coverage. Susan Geist sgeist@paychex.com Paychex Insurance Agency Inc Rochester Monroe NY Nolan Shook McKenna Warner Signed
870 2024-01-26 07:57 Anonymous (not verified) 94.188.207.228 Kodiak Group Security LLC 1978 NW 92nd CT STE 2 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. 2024-01-23 Howard Alton Johnston Jr howard@kodiakgroup.org Stuart Adair IA Joseph Crawford Howard Williams Signed (1) The corporation rejects the employers’ liability coverage. Howard Alton Johnston Jr howard@kodiakgroup.org Owner Stuart Adair Iowa Jospeh Crawford Howard Williams Signed
874 2024-01-29 14:30 Anonymous (not verified) 94.188.205.174 Proefco LLC 502 s Cadwell 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. 2024-01-30 Kendy Melendrez kendydej@gmail.com Eagle Grove IA IA Kendy Melendrez Jaime Hernandez Signed (2) The corporation declines to reject the employers’ liability coverage. Kendy Melendrez kendydej@gmail.com owner Eagle Grove IA IA Kendy Melendrez Jaime Hernandez 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
888 2024-02-12 12:35 Anonymous (not verified) 94.188.205.167 Standard Builders DBA Midwest Seamless 1930 e army post rd., Des Moines 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. 2024-02-12 Andy and Axell Construction LLC bradymaher9@gmail.com Des Moines Polk IA Michael Maher Brady Maher Signed (1) The corporation rejects the employers’ liability coverage. michael maher mikemaher@midwestseamless.com Owner/President PRAIRIE CITY Jasper IA Brady Maher fernando perez Signed
889 2024-02-15 13:16 Anonymous (not verified) 94.188.207.228 Five Star Hardwood LLC 3510 King Dr SW 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. 2024-02-15 Kenneth Williams kncwilliams@msn.com Cedar Rapids Linn IA Sabrina Lovell Tiffany Williams Signed (1) The corporation rejects the employers’ liability coverage. Kenneth Williams kncwilliams@msn.com Owner Cedar Rapids Linn IA Sabrina Lovell Tiffany Williams Signed
890 2024-02-19 12:07 Anonymous (not verified) 94.188.205.174 FJ Orisa Construction Inc 114 Austin Street SW 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. 2024-02-19 Jennifer LynnWeirup FJOrisaconstruction@yahoo.com Cedar Rapids Linn IA Karen Sedlacek Billie Jo Moore Signed (1) The corporation rejects the employers’ liability coverage. jennifer lynn weirup FJOrisaconstruction@yahoo.com self Cedar Rapids Iowa Iowa Karen Sedlacek Billie Jo Moore Signed
891 2024-02-19 12:09 Anonymous (not verified) 94.188.205.169 FJ Orisa Construction Inc 114 Austin Street SW 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. 2024-02-19 Felipe Aldana FJOrisaconstruction@yahoo.com Cedar Rapids Linn IA Karen Sedlacek Billie Jo Moore Signed (1) The corporation rejects the employers’ liability coverage. Felipe Aldana FJOrisaconstruction@yahoo.com officer Cedar Rapids Iowa Iowa Karen Sedlacek Billie Jo Moore Signed
894 2024-02-23 08:17 Anonymous (not verified) 94.188.207.226 MIDSTATE SOLUTION LLC 107 Harrison Dr Baxter, IA 50028 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 Kenneth Schlosser schlosser64@icloud.com Colfax Jasper IA Kinley Bethards Grant Alexander Signed (1) The corporation rejects the employers’ liability coverage. Justin Myers justinm@midstatesolution.com Owner Baxter Jasper IA Kinley Bethards Grant Alexander Signed
896 2024-02-23 16:14 Anonymous (not verified) 94.188.205.167 Convenience Stores Business Inc 1615 Bishop Ave, Waterloo, IA 50707 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. 2025-02-26 John Sarwar trampride@aol.com Waterloo Black Hawk IA . . Signed (1) The corporation rejects the employers’ liability coverage. Jason Koch jason_koch@veridiancu.org Agent Waterloo Black Hawk IA . . Signed
908 2024-03-02 14:33 Anonymous (not verified) 94.188.207.230 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 Paul Gerlich paul@gerlich.io Bettendorf scott IA Kelsey Gerlich Elora Gerlich Signed (1) The corporation rejects the employers’ liability coverage. Paul Gerlich paul@gelrich.io Owner Bettendorf Scott Iowa Kelsey Gerlich Garrett Gerlich Signed
909 2024-03-02 14:33 Anonymous (not verified) 94.188.207.224 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 Kelsey Gerlich paul@gerlich.io Bettendorf scott IA Paul Gerlich Elora Gerlich Signed (1) The corporation rejects the employers’ liability coverage. Paul Gerlich paul@gelrich.io Owner Bettendorf Scott Iowa Elora Gerlich Garrett Gerlich Signed
910 2024-03-02 14:34 Anonymous (not verified) 94.188.207.224 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 Elora 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 Garrett Gerlich 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
912 2024-03-06 16:44 Anonymous (not verified) 94.188.205.174 NeX Level Moving LLC 5634 Deerwood ST 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. 2024-03-06 Treyton Tayvon Mims treytmims@gmail.com Cedar Rapids Linn IA Jessica Mims Travis Mims Signed (1) The corporation rejects the employers’ liability coverage. Treyton Tayvon Mims treytmims@gmail.com self Cedar Rapids Linn IA Jessica Mims Travis Mims Signed
914 2024-03-08 09:02 Anonymous (not verified) 94.188.205.167 Lubbock Construction Inc 3035 66 St Shellsburg IA 52332 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-03-08 Justin L Lubbock justinlubbock@yahoo.com Shellsburg Benton IA Cherie Lynn Scott Jodie Marie Little Signed (1) The corporation rejects the employers’ liability coverage. Justin L Lubbock justinlubbock@yahoo.com President Shellsburg Benton IA Cherie Lynn Scott Jodie Marie Little Signed
915 2024-03-08 13:24 Anonymous (not verified) 94.188.205.174 One Call Exterior LLC 1918 9th St Des Moines 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. 2024-03-08 Nancy G Lopez onecallexteriors@gmail.com Des Moines Polk IA Monica Martinez Noe Ordaz Signed (1) The corporation rejects the employers’ liability coverage. Nancy G Lopez onecallexteriors@gmail.com Self Ames Story IA Monica Martinez Noe Ordaz Signed
926 2024-03-20 15:25 Anonymous (not verified) 94.188.207.230 CML Constuction LLC 2116 Park Ave Muscatine, Iowa 52761 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. 2024-03-20 CHRIS LINNENKAMP cmlconstructionllc@gmail.com Muscatine IA IA Gabriel Diaz Byron Lopez Signed (1) The corporation rejects the employers’ liability coverage. CHRIS LINNENKAMP cmlconstructionllc@gmail.com Owner Muscatine IA IA Gabriel Diaz Byron Lopez Signed
928 2024-03-21 16:20 Anonymous (not verified) 94.188.207.230 Midwest Premier Painting 5496 Hunt Rd, 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. 2024-03-21 Christopher West cswest1974@yahoo.com Burlington Des Moines IA Amy West McKenzie West Signed (1) The corporation rejects the employers’ liability coverage. Christopher West cswest1974@yahoo.com Owner Burlington Des Moines IA Amy Wets McKenzie West Signed
934 2024-03-24 19:23 Anonymous (not verified) 94.188.207.230 Dave Mckee 3261 old river 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. 2024-03-23 Dave mckee wildride1969@gmail.com Cedar Rapids Lynn Ia Dave mckee Valerie mckee Signed (1) The corporation rejects the employers’ liability coverage. Dave mckee wildride1969@gmail.com Owner Cedar Rapids Lynn Ia David mckee Valerie mckee Signed
937 2024-03-30 17:30 Anonymous (not verified) 94.188.205.167 AR Drilling LLC 1821 Roebling Rd, 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. 2024-03-30 Luis Serrano serranoluis7667@gmail.com Adel Dallas IA Kelly green Thomas Green Signed (1) The corporation rejects the employers’ liability coverage. Luis Serrano serranoluis7667@gmail.com Owner Adel Dallas IA Kelly Green Thomas Green Signed
938 2024-04-01 07:12 Anonymous (not verified) 94.188.207.225 Martinez HVAC Construction LLC 512 Anderson st jewell IA 50130 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. 2024-04-01 Felipe Martinez miguelrmartinez26@gmail.com Jewell Hamilton IA Brady Cooper Job Cooper Signed (1) The corporation rejects the employers’ liability coverage. Felipe Martinez miguelrmartinez26@gmail.com owner Jewell Hamilton IA Brady Cooper Job Cooper 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
947 2024-04-05 09:55 Anonymous (not verified) 94.188.207.228 Foley Contracting LLC 6730 Double Eagle Dr., 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. 2024-04-05 Samuel Nathan Foley foleycontracting@gmail.com Davenport Scott IA Gaynelle Warren Evon McNeal Signed (1) The corporation rejects the employers’ liability coverage. Samuel Foley foleycontracting@gmail.com Owner Davenport Scott IA Gaynelle Warren Evon McNeal Signed
948 2024-04-05 16:18 Anonymous (not verified) 94.188.205.168 Preventive Health Center of Iowa City, PLLC 221 E College St, Suite 211, Eastwind Healing Center, Iowa City, IA 52240 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-05 C Andi Woods phcic52240@gmail.com Iowa City Johnson ia Nancy Martin Timmy Ungs Signed (1) The corporation rejects the employers’ liability coverage. C Andi Woods phcic52240@gmail.com Owner Iowa City Johnson IA Nancy Martin Timmy Ungs Signed
963 2024-04-29 17:42 Anonymous (not verified) 94.188.207.227 Total Construction Inc 4607 S Ridge Rd Sioux City IA 51106 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. 2024-04-29 Daniel J Jennett II dj_jennett@hotmail.com Sioux City Woobury IA Julia L Lesko Olivia J Lesko Signed (1) The corporation rejects the employers’ liability coverage. Daniel J Jennett II dj_jennett@hotmail.com President Sioux City Woodbury IA Julia L Lesko Olivia J Lesko Signed
967 2024-05-01 06:30 Anonymous (not verified) 94.188.207.224 Cael Gulrud 206 W Main St Calmar, IA, 52132 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-01 Brandon Gulrud mojopants21@gmail.com Waterloo Blackhawk IA Victoria Bacon-Ortiz David Gulrud Signed (1) The corporation rejects the employers’ liability coverage. Cael Gulrud gulrud8728@gmail.com Owner Calmar Winneshiek IA Victoria Bacon-Ortiz David Gulrud Signed
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
976 2024-05-08 11:00 Anonymous (not verified) 94.188.205.177 N MCMANUS ENTERPRISES LLC 2812 Giles St, WDM IA 50265 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-08 NATHAN MCMANUS nathan.mcmanus55@gmail.com DES MOINES POLK IA TRENA MCCRAINE MATT CALE Signed (1) The corporation rejects the employers’ liability coverage. NATHAN MCMANUS nathan.mcmanus55@gmail.com OWNER DES MOINES POLK IA TRENA MCCRAINE MATT CALE Signed
983 2024-05-11 12:27 Anonymous (not verified) 94.188.207.225 Aluminum King MFG LTD 700 E Van Buren St, Mitchell, IA 50461 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. 2024-05-11 Jeremy Mostek katie@flashingthunder.com Mitchell Mitchell IA Kristy Wolfe Tami Towne Signed (1) The corporation rejects the employers’ liability coverage. Tami Towne ttowne@ryderinsurance.com Agent Grand Island Hall NE Kristy Wolfe Katherine Mostek Signed
985 2024-05-13 17:15 Anonymous (not verified) 94.188.207.225 Rail and Road Equipment Co 1797 G50 HWY. St. Charles, IA. 50240 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. 2024-05-13 Jeffrey Pontier railandroad@myomnotel.com St Charles Warren IA Abbi Goering Travis Allen Signed (1) The corporation rejects the employers’ liability coverage. Jeffrey Pontier railandroad@myomnitel.com President St Charles Warren IA Abbi Goering Travis Allen Signed
986 2024-05-13 17:26 Anonymous (not verified) 94.188.207.229 Rail and Road Equipment Co 1797 G50 HWY. St. Charles, IA. 50240 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. 2024-05-13 Ranae Pontier railandroad@myomnitel.com St Charles Warren IA Abbi Goering Travis Allen Signed (1) The corporation rejects the employers’ liability coverage. Ranae Pontier railandroad@myomnitel.com Vice President St Charles Warren IA Abbi Goering Travis Allen 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
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
398 2022-02-01 18:50 Anonymous (not verified) 172.58.83.243 essential renovation LLC 516 e center st, freeport il 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. 2022-02-01 teodoro jimenez essentialrenovations.llc@gmail.com freeport stephenson il adam spear karly spear Signed (1) The corporation rejects the employers’ liability coverage. sandra cuatlatl essentialrenovations.llc@gmail.com owner freeport stephenson il adam spear karly spear 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
710 2023-07-21 08:26 Anonymous (not verified) 94.188.205.169 Dream Team Anesthesia, Inc. 2800 E. Enterprise Ave, Ste 333, 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. 2023-07-21 Jesse Chiu jessechiu2@yahoo.com Sterling Whiteside IL Joseph Chiu Kin Chiu Signed (1) The corporation rejects the employers’ liability coverage. Jesse Chiu jessechiu2@yahoo.com President Waterloo Polk Iowa Joseph Chiu Kin Chiu Signed
844 2023-12-29 08:28 Anonymous (not verified) 94.188.207.226 Emcubed Enterprises, Inc 979 40th Ave, Bettendorf, IA 52722 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-29 Bradley David Morrison brad@riverbendsignworks.com Moline Rock Island IL David Rodriguez Lisbet Lule Signed (1) The corporation rejects the employers’ liability coverage. Bradley David Morrison brad@riverbendsignworks.com Owner Moline Rock Island IL David Rodriguez Lisbet Lule Signed
862 2024-01-22 13:55 Anonymous (not verified) 94.188.207.228 Emcubed Enterprises, Inc 979 40th Ave, Bettendorf, IA 52722 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-22 Bradley D Morrison brad@riverbendsignworks.com Moline Rock Island IL Richard Henning Kyle Sebben Signed (1) The corporation rejects the employers’ liability coverage. Brad Morrison brad@riverbendsignworks.com Owner Moline Rock Island IL Richard Henning Kyle Sebben Signed
965 2024-04-30 10:47 Anonymous (not verified) 94.188.205.177 Billy Dudock 148818 Argo Fay Rd I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-04-30 Billy Dudock mitzi@bruggemanlumber.com Thompson Carroll IL Roger Gibbs Mitzi Hoeger Signed (1) The corporation rejects the employers’ liability coverage. Billy Dudock mitzi@bruggemanlumber.com Self Thompson Carroll Il Roger Gibbs Mitzi Hoeger 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
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
23 2019-12-31 09:01 Anonymous (not verified) 65.126.161.162 Shawn Watson DBA SW Painting 1205 13th Ave Orion, IL 61273 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. 2019-12-31 Shawn Michael Watson None@none.com Orion Henry Illinois Sarah Robertson Beth Welzenbach Signed (1) The corporation rejects the employers’ liability coverage. Shawn Watson None@none.com Owner Orion Henry Illinois Sarah Robertson Beth Welzenbach Signed
327 2021-09-07 08:58 Anonymous (not verified) 173.28.32.129 Sas Entertainment, Inc. PO Box 47 LeClaire, IA 52753 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. 2021-09-07 Randy Saskowski sales@sasdjs.com Geneseo henry illinois Dan Terry Joe Roberts Signed (1) The corporation rejects the employers’ liability coverage. randy Saskowski sales@sasdjs.com President Geneseo henry illinois Dan Terry Joe Roberts Signed