600 |
2023-02-16 16:06 |
Anonymous (not verified) |
94.188.207.225 |
Friday After Work LLC |
2526 Rainbow Drive, Cedar Falls, IA 50613 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-01 |
Joshua Carder |
josh.cve@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Brady Huls |
Tyler Reynolds |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brent Dunlop |
fawconstruction.ia@gmail.com |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
Brady Huls |
Tyler Reynolds |
Signed |
601 |
2023-02-16 16:08 |
Anonymous (not verified) |
94.188.207.223 |
Friday After Work LLC |
2526 Rainbow Drive, Cedar Falls, IA 50613 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-01 |
Tyler Reynolds |
tyler.cve@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Brady Huls |
Joshua Carder |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brent Dunlop |
fawconstruction.ia@gmail.com |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
Brady Huls |
Joshua Carder |
Signed |
602 |
2023-02-16 16:10 |
Anonymous (not verified) |
94.188.207.228 |
Friday After Work LLC |
2526 Rainbow Drive, Cedar Falls, IA 50613 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-01 |
Brady John Huls |
brady.cve@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Tyler Reynolds |
Joshua Carder |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brent Dunlop |
fawconstruction.ia@gmail.com |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
Tyler Reynolds |
Joshua Carder |
Signed |
603 |
2023-02-16 16:11 |
Anonymous (not verified) |
94.188.207.223 |
Transcend Mind Body Wellness and Floatation Clinic |
409 Washington Street, Cedar Falls, IA 50613 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-01 |
Morgan Huls |
transcendcedarfalls@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Brady Huls |
Ashlyn Henry |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brady Huls |
transcendcfo@gmail.com |
CFO |
Cedar Falls |
Black Hawk |
Iowa |
Morgan Huls |
Ashlyn Henry |
Signed |
604 |
2023-02-16 16:13 |
Anonymous (not verified) |
94.188.207.226 |
Transcend Mind Body Wellness and Floatation Clinic |
409 Washington Street, Cedar Falls, IA 50613 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-01-01 |
Brady Huls |
brady.huls@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Morgan Huls |
Ashlyn Henry |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Morgan Huls |
transcendcedarfalls@gmail.com |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
Brady Huls |
Ashlyn Henry |
Signed |
682 |
2023-06-07 16:10 |
Anonymous (not verified) |
94.188.207.223 |
Jake's Insulation Inc. |
2020 Valley High Dr. Cedar Falls, IA |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-07 |
Jacob Ryan Smalley |
jakersmalley@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Emily D Smalley |
Allison L Smalley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jacob Ryan Smalley |
jakersmalley@gmail.com |
President |
Cedar Falls |
Black Hawk |
Iowa |
Emily Smalley |
Allison Smalley |
Signed |
40 |
2020-02-14 09:22 |
Anonymous (not verified) |
50.83.38.221 |
Pa's Construction LLC |
2350 Glass RD 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. |
2020-02-14 |
Daniel Saunders |
dan2112411@yahoo.com |
Cedar Rapids |
USA_IA |
USA_IA |
Walt Cheney |
Becky Cheney |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Saunders |
dan2112411@yahoo.com |
Owner- Manager |
Cedar Rapids |
USA_IA |
USA_IA |
Walt Cheney |
Becky Cheney |
Signed |
45 |
2020-03-10 10:24 |
Anonymous (not verified) |
204.141.214.180 |
Shamrock Screenprinting Inc |
2710 Granite Ct 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. |
2020-03-10 |
Lori Handley |
lori.handley@aol.com |
Cedar Rapids |
Linn |
IA |
David Handley |
Beth Barta |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lori Handley |
lori.handley@aol.com |
VP |
Cedar Rapids |
Linn |
IA |
David Handley |
Beth Barta |
Signed |
46 |
2020-03-10 10:26 |
Anonymous (not verified) |
204.141.214.180 |
Shamrock Screenprinting Inc |
2710 Granite Ct 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. |
2020-03-10 |
David Handley |
davehandley53@gmail.com |
Cedar Rapids |
Linn |
IA |
Lori Handley |
Beth Barta |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lori Handley |
Lori.handley@aol.com |
VP |
Cedar Rapids |
Linn |
IA |
Lori Handley |
Beth Barta |
Signed |
71 |
2020-04-27 16:23 |
Anonymous (not verified) |
140.82.166.162 |
Loss Control Specialist Inc |
1409 Jackson Woods Ct NW Cedar Rapids, IA 52409 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-28 |
James Riggert |
jim@losscontrolspecialist.com |
Cedar Rapids |
Linn |
Iowa |
Megan Thomas |
Jessica Droppert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Riggert |
jim@losscontrolspecialist.com |
President |
Cedar Rapids |
Linn |
Iowa |
Megan Thomas |
Jessica Droppert |
Signed |
72 |
2020-04-27 16:24 |
Anonymous (not verified) |
140.82.166.162 |
Loss Control Specialist Inc |
1409 Jackson Woods Ct NW Cedar Rapids, IA 52409 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-28 |
Pamala Riggert |
jim@losscontrolspecialist.com |
Cedar Rapids |
Linn |
Iowa |
Megan Thomas |
Jessica Droppert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Pamala Riggert |
jim@losscontrolspecialist.com |
Secretary |
Cedar Rapids |
Linn |
Iowa |
Megan Thomas |
Jessica Droppert |
Signed |
91 |
2020-06-17 17:47 |
Anonymous (not verified) |
166.182.83.28 |
BJJ Painting Inc |
6940 Rolling Ridge CT SW Cedar Rapids IA 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-06-17 |
Bradley Johnson |
brad.johnson@fivestarpainting.com |
Cedar Rapids |
Linn |
Iowa |
Mike McClure |
Tony Gaiffe |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley Johnson |
brad.johnson@fivestarpainting.com |
President |
Cedar Rapids |
Linn |
Iowa |
Mike McClure |
Tony Gaiffe |
Signed |
132 |
2020-11-03 13:22 |
Anonymous (not verified) |
173.22.125.16 |
BeraTek Industries |
407 9th Ave SE, Cedar Rapids, IA 52401 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-11-03 |
Ethan Davidson |
edavidson@beratek-industries.com |
Cedar Rapids |
Linn |
Iowa |
Raymond Gerald Beranek |
Ethan Paul Davidson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ethan Paul Davidson |
edavidson@beratek-industries.com |
President |
Cedar Rapids |
Linn |
Iowa |
Raymond Gerald Beranek |
Ethan Paul Davidson |
Signed |
140 |
2020-11-25 12:43 |
Anonymous (not verified) |
63.152.43.202 |
All Heart Staffing, Inc. |
4403 1ST AVE. SE, SUITE 310, 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. |
2020-11-01 |
Joel Katcher |
Joel@AllHeartStaffing.com |
CEDAR RAPIDS |
IA |
United States |
Andy Becker |
Kathryn Brown |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joel Katcher |
Joel@AllHeartStaffing.com |
President |
CEDAR RAPIDS |
IA |
United States |
Andy Becker |
Kathryn Brown |
Signed |
274 |
2021-06-14 08:34 |
Anonymous (not verified) |
207.191.207.6 |
Total Health Rehabilitation PC |
4332 Pioneer Tr SE, Cedar Rapids, IA 52403 |
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. |
2021-06-14 |
Suzanne E. Cooper |
tcc@acterragroup.net |
Cedar Rapids |
Linn |
Iowa |
Tad C Cooper |
Hallie S Cooper |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Suzanne E. Cooper |
tcc@acterragroup.net |
President |
Cedar Rapids |
Linn |
Iowa |
Tad C Cooper |
Hallie S Cooper |
Signed |
275 |
2021-06-15 13:23 |
Anonymous (not verified) |
172.98.131.84 |
JAVIER CONSTRUCTION INC |
2503 Canyon 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. |
2021-06-15 |
Javier Adana |
Javierconstruction88@gmail.com |
CEDAR RAPIDS |
LINN |
IOWA |
JASON SCHICK |
LADONNA SCHICK |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
JASON SCHICK |
JASONSCHICK@NEIGHBORINSURANCE.COM |
INSURANCE AGENT |
CEDAR RAPIDS |
LINN |
IOWA |
JASON SCHICK |
LADONNA SCHICK |
Signed |
289 |
2021-07-22 17:47 |
Anonymous (not verified) |
172.58.83.5 |
Javier Construction INC |
2503 canyon st sw Cedar Rapids,iowa 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. |
2021-07-22 |
Javier Aldana Fuentes |
Javierconstruction88@gmail.com |
Cedar Rapids |
Linn |
Iowa |
DaZsa Aldana |
Donya Fleetwood |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Javier Aldana Fuentes |
Javierconstruction88@gmail.com |
owner |
Cedar Rapids |
LInn |
Iowa |
DaZsa Aldana |
Donya Fleetwood |
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 |
302 |
2021-08-04 10:08 |
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 |
Charles Nejdl |
chucknejdl@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Melanie Heitman |
Dan Lillis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Charles Nejdl |
chucknejdl@gmail.com |
Vice President |
Cedar Rapids |
Linn |
Iowa |
Melanie Heitman |
Dan Lillis |
Signed |
342 |
2021-10-06 11:02 |
Anonymous (not verified) |
192.95.124.125 |
Jeffrey Wilharm MDPC |
9100 C St., Cedar Rapids, IA 52404-9160 |
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. |
2021-10-06 |
Jeffrey Wilharm |
wilharmjeffrey@gmail.com |
Cedar Rapids |
Linn |
IA |
John Yundt |
Lori Smith |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey Wilharm |
wilharmjeffrey@gmail.com |
President |
Cedar Rapids |
Linn |
IA |
John Yundt |
Lori Smith |
Signed |
430 |
2022-03-24 14:47 |
Anonymous (not verified) |
173.30.76.116 |
Franky's Construction |
1419 Acacia Dr 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. |
2022-03-24 |
Franky Ackley |
fackley1981@gmail.com |
Cedar Rapids |
Linn |
IA |
Rick DeNeve |
Kailee Carstensen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Franky Ackley |
fackley1981@gmail.com |
Owner |
Cedar Rapids |
Linn |
IA |
Rick DeNeve |
Kailee Carstensen |
Signed |
519 |
2022-07-22 13:55 |
Anonymous (not verified) |
162.253.44.28 |
Seeger Truck Trailer Repair, Inc. |
1125 66th AVE 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. |
2022-08-01 |
Eldora Seegers |
royalwsilverII@gmail.com |
Cedar Rapids |
Linn |
Iowa |
John Seegers |
Julie Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Eldora Seergers |
royalwsilverII@gmail.com |
Officer |
Cedar Rapids |
Linn |
Iowa |
John Seegers |
Julie Jones |
Signed |
524 |
2022-08-08 17:13 |
Anonymous (not verified) |
50.82.182.101 |
Top Dog Tile Installation |
8403 Brighton Court 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. |
2022-08-08 |
Philip McCurdy |
tiletopdog@aol.com |
Cedar Rapids |
Linn |
IA |
Joshua Walter Schumacher |
Jeffrey Gerard Tilkes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Philip McCurdy |
tiletopdog@aol.com |
Owner |
Cedar Rapids |
Linn |
IA |
Joshua Walter Schumacher |
Jeff Gerard Tilkes |
Signed |
543 |
2022-09-27 08:52 |
Anonymous (not verified) |
204.155.61.217 |
Ron Godwin, Inc |
PO Box 2805, Cedar Rapids, IA 52406 |
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 |
Ron Godwin |
ronjgodwin@aol.com |
Cedar Rapids |
Linn |
Iowa |
Molly Feldman |
Sharon Naber |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ron Godwin, Inc |
ronjgodwin@aol.com |
president |
Cedar Rapids |
Linn |
Iowa |
Molly Feldman |
Sharon Naber |
Signed |
556 |
2022-10-12 14:02 |
Anonymous (not verified) |
204.155.61.217 |
Embassy Catering, Inc |
PO Box 2805 |
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. |
2022-09-23 |
Ron Godwin |
ronjgodwin@aol.com |
Cedar Rapids |
Linn |
Iowa |
Molly Feldman |
Sharon Naber |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Embassy Catering, Inc. |
ronjgodwin@aol.com |
president |
Cedar Rapids |
Linn |
Iowa |
Molly Feldman |
Sharon Naber |
Signed |
562 |
2022-11-04 10:32 |
Anonymous (not verified) |
98.159.123.124 |
Alli-Center |
555 Cameron Way Unit 2 North Liberty Iowa 52317 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-11-04 |
Bonnie Seely |
bseely4@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Jonah C Seely |
Hannah Seely |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bonnie Seely |
bseely4@gmail.com |
Owner/Self |
Cedar Rapids |
Linn |
Iowa |
Jonah Seely |
Hannah Seely |
Signed |
628 |
2023-03-21 12:07 |
Anonymous (not verified) |
94.188.207.226 |
Deep Cleaning Janitorial Inc |
3131 33rd Ave SW Ceder 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. |
2023-03-21 |
Paul Mwai |
deepcleaning0142@gmail.com |
Cedar Rapids |
IA |
United States |
Mary Ngotho |
John Johnson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ray Robertson |
deepcleaning0142@gmail.com |
Co-Owner |
Cedar Rapids |
Linn |
United States |
John Johnson |
Mary Ngotho |
Signed |
629 |
2023-03-21 12:14 |
Anonymous (not verified) |
94.188.207.230 |
Deep Cleaning Janitorial Inc |
3131 33rd Ave SW Ceder 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. |
2023-03-21 |
Ray Robertson |
deepcleaning0142@gmail.com |
Cedar Rapids |
linn |
United States |
Shelley Robertson |
William Robertson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Mwai |
deepcleaning0142@gmail.com |
Co-Owner |
Cedar Rapids |
Linn |
IA |
Shelley Robertson |
William Robertson |
Signed |
650 |
2023-04-10 13:06 |
Anonymous (not verified) |
94.188.205.168 |
Deep Cleaning Janitorial Inc |
3131 33rd Ave SW Ceder 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. |
2023-04-11 |
Paul Mwai |
deepcleaning0142@gmail.com |
Cedar Rapids |
IA |
United States |
Mary Ngotho |
John Johnson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ray Robertson |
deepcleaning0142@gmail.com |
Co-Owner |
Cedar Rapids |
Linn |
United States |
Shelley Robertson |
William Robertson |
Signed |
651 |
2023-04-10 13:21 |
Anonymous (not verified) |
94.188.205.175 |
Deep Cleaning Janitorial Inc |
3131 33rd Ave SW Ceder 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. |
2023-04-10 |
Ray Robertson |
deepcleaning0142@gmail.com |
Cedar Rapids |
IA |
United States |
Shelley Robertson |
William Robertson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Mwai |
deepcleaning0142@gmail.com |
Co-Owner |
Cedar Rapids |
Linn |
United States |
Mary Ngotho |
John Johnson |
Signed |
693 |
2023-06-19 15:48 |
Anonymous (not verified) |
94.188.207.224 |
mike mcfarland |
7212 parkwood ln 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. |
2023-06-19 |
michael chad mcfarland |
mikecmcfarland@gmail.com |
cedar rapids |
linn |
United States |
Omar M Zepeda |
jamie mcfarland |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
michael chad mcfarland |
mikecmcfarland@gmail.com |
myself |
cedar rapids |
linn |
United States |
Omar M Zepeda |
jamie mcfarland |
Signed |
700 |
2023-06-22 11:03 |
Anonymous (not verified) |
94.188.207.229 |
WIT Systems Corporation |
313 Brentwood Dr 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. |
2023-06-22 |
DOUGLAS K WILLIAMS |
dkwilliams@witsystems.com |
Cedar Rapids IA |
Linn |
CT |
Patrick Gavin |
Kaley Gavin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
DOUGLAS K WILLIAMS |
dkwilliams@witsystems.com |
President |
CEDAR RAPIDS |
IA |
United States |
Patrick Gavin |
Kaley Gavin |
Signed |
711 |
2023-07-24 12:04 |
Anonymous (not verified) |
94.188.205.176 |
HAIGH & ESPE LIMITED |
1198 GRAND AVE, MARION, IA 52302 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-24 |
LYNN M. HAIGH |
ADAMSTILEANDSTONE@GMAIL.COM |
Cedar Rapids |
Linn |
Iowa |
DAVID REIBSAMEN |
STACEY ROGERS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LYNN M. HAIGH |
ADAMSTILEANDSTONE@GMAIL.COM |
CORP. SECRETARY |
CEDAR RAPIDS |
LINN |
IOWA |
DAVID REIBSAMEN |
STACEY ROGERS |
Signed |
715 |
2023-07-26 11:23 |
Anonymous (not verified) |
94.188.207.226 |
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 |
Douglas James Lampe |
lampeappliance@gmail.com |
Cedar Rapids |
Linn |
IA |
John Kenneth Lampe |
Jared Joshua Lampe |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Douglas James Lampe |
lampeappliance@gmail.com |
President |
CEDAR RAPIDS |
IA |
United States |
John Kenneth Lampe |
Jared Joshua Lampe |
Signed |
716 |
2023-07-26 11:27 |
Anonymous (not verified) |
94.188.207.228 |
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 |
John Kenneth Lampe |
lampeappliance@gmail.com |
CEDAR RAPIDS |
Linn |
Iowa |
Douglas James Lampe |
Jared Joshua Lampe |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Douglas James Lampe |
lampeappliance@gmail.com |
President |
CEDAR RAPIDS |
IA |
United States |
John Kenneth Lampe |
Jared Joshua Lampe |
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 |
723 |
2023-08-01 15:37 |
Anonymous (not verified) |
94.188.205.169 |
Flow Media, Inc |
1710 Wenig Rd 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. |
2023-08-01 |
Courtney Tabelisma Ball |
courtney@flowmedia.com |
Cedar Rapids |
IA |
United States |
Hannah Jane White |
Gregory Michael White |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Courtney Tabelisma Ball |
courtney@flowmedia.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Sonya Catherine Geenen |
Gregory Michael White |
Signed |
748 |
2023-08-20 14:18 |
Anonymous (not verified) |
94.188.205.177 |
NexLevelMoving |
1186 capital 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. |
(2) I decline to reject the employer’s liability coverage. |
2023-08-16 |
Ethan Daniel Sailer |
ethan.sailer@hscsi.net |
Cedar Rapids |
Linn County |
Iowa |
Denis Sailer |
Penny Sailer |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Tarin Erenberger |
tarin.nexlevelmoving@gmail.com |
Employee |
Cedar Rapids |
Linn County |
Iowa |
Taj Barrett |
Taj Barrett |
Signed |
753 |
2023-08-21 14:21 |
Anonymous (not verified) |
94.188.205.174 |
NexLevelMoving |
1186 Capital Dr Sw, Cedar Rapids |
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. |
2023-08-23 |
Ethan Daniel Sailer |
ethan.sailer@hscsi.net |
Cedar Rapids |
Linn County |
Iowa |
Penny Sailer |
Denis Sailer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ethan Daniel Sailer |
ethan.sailer@hscsi.net |
Self |
Cedar Rapids |
Linn County |
Iowa |
Penny Sailer |
Denis Sailer |
Signed |
754 |
2023-08-21 17:14 |
Anonymous (not verified) |
94.188.205.177 |
Burgess Investments DBA Heartland Pest Control Inc |
PO Box 8043 Cedar Rapids, IA 52408 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-21 |
CURT BURGESS |
curtburgess73@gmail.com |
CEDAR RAPIDS |
IA |
United States |
Doug Wilson |
Michael McMeins |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CURT BURGESS |
curtburgess73@gmail.com |
Self |
CEDAR RAPIDS |
IA |
United States |
Doug Wilson |
Michael McMeins |
Signed |
771 |
2023-09-17 13:33 |
Anonymous (not verified) |
94.188.205.176 |
Apex Landlord Services LLC |
429 Shetland Dr 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. |
2023-09-17 |
Benjamin Walhood |
info@apexlandlordservices.com |
Cedar Rapids |
Linn |
Iowa |
Justin Goebel |
Jennifer Goebel |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Benjamin Walhood |
info@apexlandlordservices.com |
Managing Member |
Cedar Rapids |
Linn |
Iowa |
Justin Goebel |
Jennifer Goebel |
Signed |
798 |
2023-10-20 10:54 |
Anonymous (not verified) |
94.188.205.177 |
Connerley Construction Inc |
5915 4Th St. SW Cedar Rapids, Iowa 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. |
2023-10-20 |
Allen Connerley |
betterrentalsbyconnerley@aol.com |
CEDAR RAPIDS |
Linn |
Iowa |
Nika Mefford |
Duane Anderson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Connerley Construction Inc |
Connerleyconstruction@gmail.com |
Owner |
Cedar Rapids |
Linn |
IA |
Nika Mefford |
Duane Anderson |
Signed |
804 |
2023-10-31 13:04 |
Anonymous (not verified) |
94.188.207.226 |
NeX Level Restoration LLC |
314 8th ST 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. |
2023-10-31 |
Bobby Caldwell SR |
blc5000@msn.com |
Cedar Rapids |
Linn |
IA |
Adam Feldmann |
Tarin Tanner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bobby Caldwell |
blc5000@msn.com |
Self |
Cedar Rapids |
Linn |
IA |
Adam Feldmann |
Tarin Tanner |
Signed |
813 |
2023-11-14 13:00 |
Anonymous (not verified) |
94.188.207.226 |
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. |
2023-11-14 |
Garrett Allen Reno |
garrettreno2001@gmail.com |
Tipton |
Cedar |
Iowa |
Bridget Camp |
Tarin Erenberger |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tarin Erenberger |
tarin.nexlevelusa@gmail.com |
Operations Director |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Garrett Reno |
Signed |
853 |
2024-01-16 13:21 |
Anonymous (not verified) |
94.188.207.230 |
NeX Level Moving |
5634 Deerwood St SW Cedar Rapids, IA 52404 United States |
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. |
2024-01-16 |
Hayden Schaefer Wagner |
24haywag24@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Stephanie Allegra Wagner |
Hayden Schaefer Wagner |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Hayden Schaefer Wagner |
24haywag24@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Hayden Schaefer Wagner |
Stephanie Allegra Wagner |
Signed |
855 |
2024-01-17 14:55 |
Anonymous (not verified) |
94.188.205.177 |
NexLevel Moving |
5634 Deerwood 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. |
2024-01-17 |
LaPriest Green |
lapriestg@gmail.com |
Cedar Rapids |
Linn County |
Iowa |
Adam Feldmann |
LaPriest Green |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LaPriest Green |
lapriestg@gmail.com |
Employee |
Cedar Rapids |
Linn County |
Iowa |
Adam Feldmann |
LaPriest Green |
Signed |
856 |
2024-01-17 15:09 |
Anonymous (not verified) |
94.188.205.167 |
Nex Level Moving, LLC |
5634 Deerwood 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. |
2024-01-17 |
LaPriest Green |
lapriestg@gmail.com |
Cedar Rapids |
Linn County |
Iowa |
Adam Feldmann |
LaPriest Green |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LaPriest Green |
lapriestg@gmail.com |
Employee |
Cedar Rapids |
Linn County |
Iowa |
Adam Feldmann |
LaPriest Green |
Signed |
861 |
2024-01-19 11:52 |
Anonymous (not verified) |
94.188.207.228 |
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. |
2024-01-19 |
Martavian |
mborseth0110@gmail.com |
Cedar rapids |
Linn |
Iowa |
Christine B. |
Jenny B. |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Martavian Borseth |
mborseth0110@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Christine B. |
Jenny B. |
Signed |
868 |
2024-01-25 14:08 |
Anonymous (not verified) |
94.188.207.229 |
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. |
2024-01-25 |
Trevor McCauley |
jhawktm@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Bridget |
Camp |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Trevor McCauley |
jhawktm@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Trevor McCauley |
Signed |
871 |
2024-01-26 09:16 |
Anonymous (not verified) |
94.188.205.168 |
NeX Level Restoration |
314 8th St NW, 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. |
2024-01-26 |
Trevor McCauley |
jhawktm@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Bridget Camp |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Trevor McCauley |
jhawktm@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Bridget Camp |
Bridget Camp |
Signed |