158 |
2021-01-06 15:54 |
Anonymous (not verified) |
216.81.153.249 |
Al's Inc DWB CW&T |
1509 Richland Drive, Storm Lake, IA 5058 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-29 |
Julie Deucker |
NONE@GMAIL.COM |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Julie Duecker |
None@gmail.com |
Owner |
Storm Lake |
Buena Vista |
IA |
Jared Brashears |
Mary Jo Olthoff |
Signed |
148 |
2020-12-30 08:22 |
Anonymous (not verified) |
166.181.83.201 |
Elite Carpentry |
P.O. Box 1162 Bettendorf Iowa 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. |
2020-12-30 |
Jeffrey D Leech |
Elitecarpentryqc@gmail.com |
Bettendorf |
Scott |
Iowa |
Jeremy Havens |
Michael Rodriguez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey D Leech |
Elitecarpentryqc@gmail.com |
Owner |
Bettendorf |
Scott |
Iowa |
Jeremy Havens |
Michael Rodriguez |
Signed |
151 |
2021-01-01 11:26 |
Anonymous (not verified) |
75.162.130.160 |
The Product Boss LLC |
20 Mountain Way, West Orange, NJ 07052 |
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. |
2021-01-01 |
Minna Khounlo-Sithep |
minna@theproductboss.com |
Ankeny |
IA |
IA |
Nalinh Sithep |
Suzzan Khounlo |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Minna Khounlo-Sithep |
minnaks@gmail.com |
Co-Owner |
Ankeny |
IA |
IA |
Nalinh Sithep |
Suzzan Khounlo |
Signed |
230 |
2021-04-06 21:15 |
Anonymous (not verified) |
173.23.145.187 |
Jose J Framing |
5301 SE 24th St. Des Moines IA 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-01-01 |
Jose J. Castillo |
castillojosejonathan7@gmail.com |
Des Moines |
Polk |
United States |
Perla Landaverde Garcia |
Alma Y. Gaytan |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jose J. Castillo |
castillojosejonathan7@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Perla Landaverde Garcia |
Alma Y. Gaytan |
Signed |
321 |
2021-08-27 16:10 |
Anonymous (not verified) |
173.30.51.29 |
Diamond Bath LLC |
3184 Berkshire PKwy Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-02 |
Patricia Fisk |
diamondbathllc@gmail.com |
Clive |
Iowa |
United States |
Joshua A Fisk |
John S Lanscak III |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Patricia Fisk |
diamondbathllc@gmail.com |
Owner/CEO |
Clive |
Iowa |
United States |
Joshua A Fisk |
John S Lanscak III |
Signed |
322 |
2021-08-27 16:16 |
Anonymous (not verified) |
173.30.51.29 |
Waterfall Design LLC |
3184 Berkshire Pkwy |
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. |
2021-01-02 |
John S Lanscak III |
waterfalldesign3@gmail.com |
Clive |
IA |
United States |
Joshua A Fisk |
Patricia A Fisk |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John S Lanscak III |
waterfalldesign3@gmail.com |
Owner/CEO |
Clive |
IA |
United States |
Joshua A Fisk |
Patricia A Fisk |
Signed |
153 |
2021-01-06 13:20 |
Anonymous (not verified) |
167.142.147.6 |
PACIFIC DRYWALL CORPORATION |
105 SNYDER DRIVE HUXLEY, IOWA 50124 |
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. |
2021-01-06 |
JUAN JOSE AVALOS CASTELLANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
ANKENY |
POLK |
IOWA |
JENNIFER LYNNE ESCOBAR |
LUIS MANUEAL AVALOS CASTELANOS |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
JUAN JOSE AVALOS CASTELLANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
VICE PRESIDENT |
ANKENY |
POLKC |
IOWA |
JENNIFER LYNNE ESCOBAR |
LUIS MANUEL AVALOS CASTELANOS |
Signed |
154 |
2021-01-06 13:23 |
Anonymous (not verified) |
167.142.147.6 |
PACIFIC DRYWALL CORPORATION |
105 SNYDER DRIVE HUXLEY, IOWA 50124 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-01-06 |
LUIS MANUEL AVALOS CASTELANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
DES MOINES |
POLK |
IOWA |
JENNIFER LYNNE ESCOBAR |
JUAN JOSE AVALOS CASTELLANOS |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
LUIS MANUEL AVALOS CASTELANOS |
PACIFICDRYWALLCORP@GMAIL.COM |
PRESIDENT |
DES MOINES |
POLK |
IOWA |
JUAN JOSE AVALOS CASTELLANOS |
JENNIFER LYNNE ESCOBAR |
Signed |
272 |
2021-06-08 12:32 |
Anonymous (not verified) |
40.135.3.146 |
Gordinier Construction Inc |
9555 SE 6th Ave, Runnells IA 50237 |
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. |
2021-01-06 |
Tim Gordinier |
gordinierconstruction@gmail.com |
Runnnells |
POLK |
IA |
Robert Simmons |
Joe Meyers |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tim Gordinier |
gordinierconstruction@gmail.com |
Self |
Runnells |
Polk |
IA |
Robert Simmons |
Joe Meyers |
Signed |
273 |
2021-06-08 12:34 |
Anonymous (not verified) |
40.135.3.146 |
Gordinier Construction Inc |
9555 SE 6th Ave, Runnells IA 50237 |
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. |
2021-01-06 |
Dustin Gordinier |
gordinierconstruction@gmail.com |
Runnells |
Polk |
IA |
Robert Simmons |
Joe Meyers |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dustin Gordinier |
gordinierconstruction@gmail.com |
Self |
Runnells |
Polk |
IA |
Robert Simmons |
Joe Meyers |
Signed |
160 |
2021-01-13 10:52 |
Anonymous (not verified) |
173.190.64.239 |
united workers inc |
711 4th st ne |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-13 |
mayra sapolvada |
buck@trvnet.net |
Belmond |
wright |
iowa |
shannon muhlenbruch |
Martha Leal |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
mayra sapulvada |
buck@trvnet.net |
president |
belmond |
wright |
ia |
shannon myhlenbruch |
martha leal |
Signed |
163 |
2021-01-20 11:08 |
Anonymous (not verified) |
173.233.46.58 |
Wasmer Post 241 Department of Iowa dba The American Legion |
110 Plymouth St SW, Le Mars, IA 51031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-13 |
Kim Wittmar |
mrkmjm@yahoo.com |
Le Mars |
Plymouth |
iA |
Muriel J. MIller |
Richard P. Miller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gary L. Konz |
claim_buster@yahoo.com |
Financial Officer |
Le Mars |
Plymouth |
IA |
Muriel J. Miller |
Richard P. Miller |
Signed |
164 |
2021-01-20 11:11 |
Anonymous (not verified) |
173.233.46.58 |
Wasmer Post 241, Department of Iowa dba The American Legion |
110 Plymouth St SW, Le Mars, IA 51031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-13 |
Andrew M. Schultze |
mrkmjm@yahoo.com |
Le Mars |
Plymouth |
IA |
Muriel J. Miller |
Richard P. Miller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gary L. Konz |
claim_buster@yahoo.com |
Financial Officer |
Le Mars |
Plymouth |
IA |
Muriel J. Miller |
Richard P. Miller |
Signed |
165 |
2021-01-20 11:14 |
Anonymous (not verified) |
173.233.46.58 |
Wasmer Post 241, Department of Iowa dba The American Legion |
110 Plymouth St SW, Le Mars, IA 51031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-13 |
Matthew Larson |
mrkmjm@yahoo.com |
Alton |
Sioux |
IA |
Muriel J. Miller |
Richard P. Miller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gary L. Konz |
claim_buster@yahoo.com |
Financial Officer |
Le Mars |
Plymouth |
IA |
Muriel J. Miller |
Richard P. Miller |
Signed |
166 |
2021-01-21 08:52 |
Anonymous (not verified) |
66.102.212.10 |
English River Transport, Inc. |
2015 Highway 22, Kalona, IA 52247 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-13 |
James A Yoder |
fisheria@kctc.net |
Kalona |
Washington |
IA |
Christian Swartzentruber |
Judy Showalter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James A Yoder |
christian@fisherins.com |
President |
Kalona |
Washington |
IA |
Christian Swartzentruber |
Judy Showalter |
Signed |
161 |
2021-01-14 19:19 |
Anonymous (not verified) |
108.174.118.195 |
Four Seasons HVAC LLC |
3165 Four Seasons Drive, Stevensville, MT 59870 |
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. |
2021-01-14 |
Douglas Michael Ostrenga |
doug@fourseasonshvac.com |
Stevensville |
Ravalli |
MT |
Zachery Donald Wiediger |
Thomas Maximillian Liedtka |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Julie Ruthanne Ostrenga |
julie@fourseasonshvac.com |
Member Manager |
Stevensville |
Ravalli |
MT |
Zachery Donald Wiediger |
Thomas Maximillian Liedtka |
Signed |
162 |
2021-01-19 15:21 |
Anonymous (not verified) |
72.255.74.171 |
JD Enterprises Inc |
4807 160th Ave, Carlisle, IA 50047 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-19 |
Jim Downs |
jdowns@arrowisg.com |
Carlisle |
Warren |
Iowa |
Tyler Cataldo |
Patti Isley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jim Downs |
jdowns@arrowisg.com |
Owner |
Carlisle |
Warren |
Iowa |
Tyler Cataldo |
Patti Isley |
Signed |
171 |
2021-01-26 15:07 |
Anonymous (not verified) |
174.198.73.28 |
R. A. Snow Removals, Inc |
525 7th St. NW |
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 Aaron Snow |
rasnowremovals.inc@gmail.com |
Altoona |
Polk |
Iowa |
Shannon Keely Moses |
Jessy James Dentler |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Aaron Snow |
rasnowremovals.inc@gmail.com |
President |
Altoona |
Polk |
Iowa |
Shannon Keely Moses |
Jessy James Dentler |
Signed |
172 |
2021-01-26 19:02 |
Anonymous (not verified) |
173.17.8.56 |
Hutch's Parking Lot Sweeping |
5235 JENNIFER DR |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-26 |
Bill HUTCHINSON |
btnwhutch@aol.com |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
WHITNIE HUTCHINSON |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill HUTCHINSON |
btnwhutch@aol.com |
Self |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
WHITNIE HUTCHINSON |
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 |
188 |
2021-02-25 10:46 |
Anonymous (not verified) |
173.24.190.134 |
Shamrock Recycling, Inc. |
PO Box 304, Emmetsburg, IA 50536 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-26 |
Michael H. Flannegan |
shamrock@ncn.net |
Emmetsburg |
Palo Alto |
Iowa |
Cindy Flannegan |
Laura Sidles |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael H Flannegan |
shamrock@ncn.net |
President |
Emmetsburg |
Palo Alto |
Iowa |
Cindy Flannegan |
Laura Sidles |
Signed |
394 |
2022-01-27 12:29 |
Anonymous (not verified) |
72.255.65.83 |
Rodgers’ Building & Remodeling Inc |
1003 NW 37th Street |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-28 |
Benjamin Rodgers |
btrdsm18@gmail.com |
Ankeny |
Polk |
Iowa |
Mary Rodgers |
Larry Joel |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mary Rodgers |
steff.m2096@yahoo.com |
President |
Ankeny |
Polk |
Iowa |
Ben Rodgers |
Larry Joel |
Signed |
174 |
2021-01-29 12:08 |
Anonymous (not verified) |
108.174.118.195 |
Tempered Solutions HVAC LLC |
897 Old Corvallis Road |
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. |
2021-01-29 |
Zachery Wiediger |
temperedsolutionshvac@gmail.com |
Corvallis |
Montana |
United States |
Julie R. Ostrenga |
Douglas M. Ostrenga |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Zachery Wiediger |
temperedsolutionshvac@gmail.com |
Self |
Corvallis |
Montana |
United States |
Douglas M. Ostrenga |
Julie R. Ostrenga |
Signed |
187 |
2021-02-25 10:44 |
Anonymous (not verified) |
173.27.130.150 |
Southside Boat Club |
Post Office Box 674, Keokuk, Iowa 52632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-01 |
Michael Oney Mahoney |
southsideboatclub@gmail.com |
Keokuk |
Lee |
Iowa |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeri Denise Asbridge |
Kerryasbridge1@mediacombb.net |
Treasurer |
Hamilton |
Hancock |
Illinois |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
189 |
2021-02-25 10:56 |
Anonymous (not verified) |
173.27.130.150 |
Southside Boat Club |
Post Office Box 674, Keokuk, Iowa 52632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-01 |
Kathryn L. Farris |
southsideboatclub@gmail.com |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeri Denise Asbridge |
Kerryasbridge1@mediacombb.net |
Treasurer |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
190 |
2021-02-25 10:57 |
Anonymous (not verified) |
173.27.130.150 |
Southside Boat Club |
Post Office Box 674, Keokuk, Iowa 52632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-01 |
Kathryn L. Farris |
southsideboatclub@gmail.com |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeri Denise Asbridge |
Kerryasbridge1@mediacombb.net |
Treasurer |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
191 |
2021-02-25 11:07 |
Anonymous (not verified) |
173.27.130.150 |
Southside Boat Club |
Post Office Box 674, Keokuk, Iowa 52632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-01 |
Karen Colleen Rude |
kacee61@hotmail.com |
Keokuk |
Lee |
Iowa |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeri Asbridge |
Kerryasbridge1@mediacombb.net |
Treasurer |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
192 |
2021-02-25 11:10 |
Anonymous (not verified) |
173.27.130.150 |
Southside Boat Club |
Post Office Box 674, Keokuk, Iowa 52632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-01 |
Jeri Asbridge |
kerryasbridge1@mediacombb.net |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeri Asbridge |
Kerryasbridge1@mediacombb.net |
Treasurer |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
208 |
2021-03-16 16:19 |
Anonymous (not verified) |
204.155.61.217 |
AGSPIRE INC |
1310 Kathryn Ct Buffalo, MN 55313 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-02 |
Kent Kiebelkorn |
kent@hailmayday.com |
Buffalo |
Wright County |
Minnesota |
Docusign |
Docusign |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
unknown |
akraft@millerhartwig.com |
Unknown |
unknown |
unknown |
unknown |
unknown |
unknown |
Signed |
176 |
2021-02-03 15:02 |
Anonymous (not verified) |
174.198.90.166 |
Jesse's Embers LLC |
3301 Ingersoll Ave, Des Moines, IA, 50312 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-03 |
Deena Edelstein |
dledelstein@hotmail.com |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Deena Edelstein |
dledelstein@hotmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
177 |
2021-02-03 15:07 |
Anonymous (not verified) |
174.198.90.166 |
Jesse's Embers LLC |
3301 Ingersoll Ave, Des Moines, IA, 50312 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-03 |
Martin Scarpino |
martyscarpino@yahoo.com |
Des Moines |
Polk |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Martin Scarpino |
martyscarpino@yahoo.com |
Owner |
Des Moines |
IA |
Iowa |
Eliott Milakovich |
Amy Jones |
Signed |
210 |
2021-03-22 15:20 |
Anonymous (not verified) |
204.155.61.217 |
Agspire Inc |
1310 Kathryn Ct Buffalo, MN 55313 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-05 |
Kent Fiebelkorn |
kent@hailmayday.com |
Buffalo |
Wright County |
Minnesota |
DocuSign |
Ashley Kraft |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kent Fiebelkorn |
kent@hailmayday.com |
Owner |
Buffalo |
Wright County |
Minnesota |
DocuSign |
Ashley Kraft |
Signed |
181 |
2021-02-18 08:49 |
Anonymous (not verified) |
173.18.193.51 |
Freeman Family Farms Inc |
3125 Glasgow Rd Fairfield Iowa 52556 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-08 |
Phyllis Freeman |
jill@fullenkampins.com |
Fairfield |
Jefferson |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Phyllis Freeman |
bfree4020@gmail.com |
Secretary |
Fairfield |
Jefferson |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
182 |
2021-02-18 08:52 |
Anonymous (not verified) |
173.18.193.51 |
Freeman Family Farms Inc |
3125 Glasgow Rd Fairfield Iowa 52556 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-08 |
Bradly Freeman |
jill@fullenkampins.com |
Mt. Pleasant |
Henry |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradly Freeman |
jill@fullenkampins.com |
Treasurer |
Mt Pleasant |
Henry |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
183 |
2021-02-18 08:54 |
Anonymous (not verified) |
173.18.193.51 |
Freeman Family Farms Inc |
3125 Glasgow Rd Fairfield Iowa 52556 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-08 |
David Freeman |
jill@fullenkampins.com |
Fairfield |
Jefferson |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Freeman |
jill@fullenkampins.com |
President |
Fairfield |
Jefferson |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
202 |
2021-03-08 10:43 |
Anonymous (not verified) |
151.147.196.21 |
Iowa Gold Distributing, Inc. |
600 Iehl Street, Central City, IA 52214 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-10 |
Rebeccah Walters |
igdenv@aol.com |
Central City |
Linn |
Iowa |
William Walters |
Jennifer Leinen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rebeccah Walters |
igdenv@aol.com |
Secretary |
Central City |
Linn |
Iowa |
William Walters |
Jennifer Leinen |
Signed |
203 |
2021-03-08 10:43 |
Anonymous (not verified) |
151.147.196.21 |
Iowa Gold Distributing, Inc. |
600 Iehl Street, Central City, IA 52214 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-10 |
William R. Walters |
igdenv@aol.com |
Central City |
Linn |
Iowa |
Jennifer Leinen |
Robert L. Hammerberg |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William R. Walters |
igdenv@aol.com |
President |
Central City |
Linn |
Iowa |
Jennifer Leinen |
Robert L. Hammerberg |
Signed |
204 |
2021-03-08 10:43 |
Anonymous (not verified) |
151.147.196.21 |
Iowa Gold Distributing, Inc. |
600 Iehl Street, Central City, IA 52214 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-02-10 |
Brad Coates |
igdenv@aol.com |
Central City |
Linn |
Iowa |
William Walters |
Jennifer Leinen |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Brad Coates |
igdenv@aol.com |
Director |
Central City |
Linn |
Iowa |
William Walters |
Jennifer Leinen |
Signed |
178 |
2021-02-13 00:06 |
Anonymous (not verified) |
172.58.87.80 |
All Cut Lawncare and Landscaping LLC |
3506 Glover Ave. Des Moines Iowa 50315 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-12 |
Michael David Money |
moneymichael811@gmail.com |
Des Moines |
Polk |
Iowa |
Diana Jennings |
Deanna L Phagan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael David Miney |
mineymichael811@gmail.com |
Owner and President |
Des Moines |
Polk |
Iowa |
Diana Jennings |
Deanna L Phagan |
Signed |
196 |
2021-03-03 11:11 |
Anonymous (not verified) |
173.31.147.225 |
TLI INVESTMENTS INC |
1712 368TH AVE ESTHERVILLE, IA 51334 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-15 |
LESLI IVERSON |
TBYRDLES@YAHOO.COM |
ESTHERVILLE |
EMMET |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LESLI IVERSON |
TBYRDLES@YAHOO.COM |
PRESIDENT |
ESTHERVILLE |
EMMET |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
197 |
2021-03-03 11:16 |
Anonymous (not verified) |
173.31.147.225 |
TLI INVESTMENTS INC |
1712 368TH AVE ESTHERVILLE, IA 51334 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-15 |
TRACE IVERSON |
JOEL@WALKERINSURANCE.COM |
ESTHERVILLE |
EMMET |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
TRACE IVERSON |
TBYRDLES@YAHOO.COM |
VICE PRESIDENT |
ESTHERVILLE |
EMMET |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
179 |
2021-02-16 18:03 |
Anonymous (not verified) |
216.248.123.206 |
Outer Edge Screen Printing |
2449 68th Street Van Horne, Iowa 52346 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-16 |
Kyle Christopher Kline |
outedgekim@gmail.com |
Van Horne |
IA |
United States |
Kelsea Marie Kline |
Amber Marie Valentine |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kimberly Sue Kline |
outedgekim@gmail.com |
spouse |
Van Horne |
IA |
United States |
Kelsea Marie Kline |
Amber Lynn Valentine |
Signed |
180 |
2021-02-16 18:05 |
Anonymous (not verified) |
216.248.123.206 |
Outer Edge Screen Printing |
2449 68th Street Van Horne, Iowa 52346 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-16 |
Kimberly Sue Kline |
outedgekim@gmail.com |
Van Horne |
IA |
United States |
Amber Lynn Valentine |
Kelsea Marie Kline |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Outer Edge Screen Printing Co |
outedgekim@gmail.com |
Spouse |
Van Horne |
IA |
United States |
Amber Lynn Valentine |
Kelsea Marie Kline |
Signed |
184 |
2021-02-20 15:18 |
Anonymous (not verified) |
75.162.213.162 |
MJM, INC. |
32345 - 200TH ST., DALLAS CENTER, IA 50063 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-20 |
MICHAEL CONNOLLY |
MJMINC2000@AOL.COM |
Dallas Center |
Iowa |
United States |
Stephen L. Davis |
Jackson Plagge |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
MICHAEL CONNOLLY |
MJMINC2000@AOL.COM |
Vice President |
Dallas Center |
Iowa |
United States |
Stephen L. Davis |
Jackson Plagge |
Signed |
185 |
2021-02-23 15:16 |
Anonymous (not verified) |
173.29.151.168 |
TONY V'S PAINTING |
2316 CRESCENT AVE 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. |
2021-02-23 |
ANTHONY VANCE |
ANTHONYJV1977@GMAIL.COM |
DAVENPORT |
SCOTT |
IA |
TONY BURKHART |
RICHARD MILLER-VANCE |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ANTHONY VANCE |
ANTHONYJV1977@GMAIL.COM |
OWNER |
DAVENPORT |
SCOTT |
IA |
TONY BURKHART |
RICHARD MILLER-VANCE |
Signed |
186 |
2021-02-24 14:35 |
Anonymous (not verified) |
216.51.194.37 |
Estherville Aviation, Inc. |
1672 425th Ave, Estherville, IA 51334 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-24 |
Paul Abrams Slaughter |
estavtn@yourstarnet.net |
Estherville |
Emmet |
Iowa |
Jordan Lampman |
Dwayne Hoss |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Abrams Slaughter |
estavtn@yourstarnet.net |
President |
Estherville |
Emmet |
Iowa |
Jordan Lampman |
Dwayne Hoss |
Signed |
193 |
2021-03-02 11:32 |
Anonymous (not verified) |
50.83.72.164 |
4 corners drywall |
532 w 15 st, Davenport, iowa 52803 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2021-03-02 |
Phillip hoxsey |
Phillhoxsey81@gmail.com |
Davenport |
Scott |
Iowa |
Donivan hoxsey |
Connor ruge |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Phillip hoxsey |
Phillhoxsey81@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Donivan hoxsey |
Connor ruge |
Signed |
194 |
2021-03-02 11:42 |
Anonymous (not verified) |
50.83.72.164 |
D’s Drywall |
1217 n Blanchard 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. |
(2) I decline to reject the employer’s liability coverage. |
2021-03-02 |
Donivan hoxsey |
hdonivan@gmail.com |
Davenport |
Scott |
Iowa |
Phillip hoxsey |
Connor ruge |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Donivan hoxsey |
hdonivan@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Phillip hoxsey |
Connor ruge |
Signed |
195 |
2021-03-02 16:29 |
Anonymous (not verified) |
173.29.156.163 |
Certified drywall |
329 e.11th st Davenport, Iowa 52803 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-02 |
Thomas wells |
mikeparry783@gmail.com |
Davenport |
Scott |
Iowa |
Chyna rose pena |
Natalie parry |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Thomas wells |
mikeparry783@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Chyna rose pena |
Natalie parry |
Signed |
211 |
2021-03-25 09:10 |
Anonymous (not verified) |
204.155.61.217 |
The New Leaf Co |
1095 Oakdale Ave, St Paul, MN 55118 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-02 |
Michael Hernandaz |
liveabovethecloudz@gmail.com |
St Paul |
Dakota |
MN |
DocuSign |
Ashley Kraft |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Hernandaz |
liveabovethecloudz@gmail.com |
Ower |
St Paul |
Dakota |
mn |
DocuSign |
Ashley Kraft |
Signed |