773 |
2023-09-20 13:48 |
Anonymous (not verified) |
94.188.207.225 |
RHYO SIDING AND RESTORATION |
1475 Wilson Avenue, 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. |
2023-09-09 |
FERDIN CASTELLANOS MERINO |
ferdincastellanos7@gmail.com |
Cedar Rapids |
Linn County |
IOWA |
FERDIN CASTELLANOS MERINO |
GLORIA RODRIGUEZ |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
N/A |
customerservice@biberk.com |
N/A |
N/A |
N/A |
N/A |
N/A |
N/A |
Signed |
772 |
2023-09-18 12:52 |
Anonymous (not verified) |
94.188.207.224 |
Wallenburg Trucking LLC |
911 8th Street SW |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-18 |
Heath Ryan Wallenburg |
heathwallenburg@gmail.com |
Rock Valley |
IA |
United States |
Dustin Van Beek |
Lucas Van Engen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Deric Hill |
d.hill@joemorten.com |
Insurance |
Sioux City NE |
Dakota County |
Nebraska |
Dustin Van Beek |
Lucas Van Engen |
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 |
770 |
2023-09-14 16:23 |
Anonymous (not verified) |
94.188.205.167 |
Volt Electric Inc |
24 Thompson 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. |
2023-09-14 |
Lucas Beschta |
voltelectriciowa@gmail.com |
Palo |
IA |
United States |
Sage Stulz |
Kolt Stulz-obrien |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Full Name BRIAN C. EDDY |
BEddy@robertseddy.com |
Lawyer for the company |
Independace |
buchanan |
IA |
sage stulz |
Kolt stulz-obrien |
Signed |
769 |
2023-09-12 12:49 |
Anonymous (not verified) |
94.188.207.223 |
Southwest Sanitation |
Clarinda, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-12 |
Joshua Weed |
swsanitation@gmail.com |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lindsay Schrock |
swsanitation@gmail.com |
Treasure |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
768 |
2023-09-12 12:48 |
Anonymous (not verified) |
94.188.207.224 |
BSSI MW |
23959 580th Ave |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-28 |
Tom Barragy |
tom@agvolution.co |
Ames |
Boone |
Iowa |
Blaine Bancks |
Pete Romig |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Thomas j Barragy |
tbarragy@agvolution.co |
ownet |
AMES |
Boone |
ia |
Blaine Bancks |
Pete Romig |
Signed |
767 |
2023-09-12 12:48 |
Anonymous (not verified) |
94.188.207.223 |
Southwest Sanitation |
Clarinda, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-12 |
Lonnie Weed |
swsanitation@gmail.com |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lindsay Schrock |
swsanitation@gmail.com |
Treasure |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
766 |
2023-09-12 12:46 |
Anonymous (not verified) |
94.188.207.224 |
Southwest Sanitation |
Clarinda, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-12 |
Craig Schrock |
swsanitation@gmail.com |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lindsay Schrock |
swsanitation@gmail.com |
Treasure |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
765 |
2023-09-12 12:44 |
Anonymous (not verified) |
94.188.207.229 |
Southwest Sanitation Inc |
Clarinda, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-12 |
Lindsay A Schrock |
swsanitation@gmail.com |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lindsay Schrock |
swsanitation@gmail.com |
Treasure |
Bedford |
Taylor |
Iowa |
Robin Wilmarth |
Bryan Wilmarth |
Signed |
764 |
2023-09-10 19:18 |
Anonymous (not verified) |
94.188.205.177 |
Heartland Ultrasonography Group |
1015 Woodland Drive Carlisle, Iowa 50047 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-10 |
Bradley C Curtis |
blc735@msn.com |
Carlisle |
Warren |
Iowa |
Dane Joseph Wright |
Michael Lee Guffey |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley C Curtis |
Heartlandusgroup@outlook.com |
Co-owner llc |
Carlisle |
Warren |
Iowa |
Dane Joseph Wright |
Michael Lee Guffey |
Signed |
763 |
2023-09-05 12:31 |
Anonymous (not verified) |
94.188.205.168 |
Blue Ridge Enterprises, LLC |
604 old sixteen road Waterville, IA 52170 |
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. |
2023-09-05 |
Nathan Eldon Leas |
nleas69@gmail.com |
Waterville |
Allamakee |
Iowa |
Mark Wright |
Gary Mahr |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nathan Eldon Leas |
nleas69@gmail.com |
President/owner |
Waterville |
Allamakee |
Iowa |
Mark Wright |
Gary Mahr |
Signed |
762 |
2023-09-01 09:00 |
Anonymous (not verified) |
94.188.207.226 |
Paradigm Group, LLC |
3263 Cumming Road, Cumming, IA 50061 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-01 |
Hunter Fees |
iowatuckpointing@gmail.com |
Carlisle |
Warren |
Iowa |
Jered Holker |
Wes Duncan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ryan Shabino |
ryan@prdgmgroup.com |
Owner |
Cumming |
Madison |
Iowa |
Wes Duncan |
Jered Holker |
Signed |
761 |
2023-09-01 08:52 |
Anonymous (not verified) |
94.188.205.177 |
Paradigm Group, LLC |
3263 Cumming Road, Cumming, IA 50061 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-01 |
Rony De Leon |
ronydeleon22@icloud.com |
Des Moines |
Polk |
Iowa |
Jered Holker |
Wes Duncan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ryan Shabino |
ryan@prdgmgroup.com |
Owner |
Cumming |
Madison |
Iowa |
Wes Duncan |
Jered Holker |
Signed |
760 |
2023-09-01 08:43 |
Anonymous (not verified) |
94.188.207.226 |
Paradigm Group, LLC |
3263 Cumming Road, Cumming, IA 50061 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-09-01 |
Conor Davis |
conor@cdavisflooring.com |
Urbandale |
Dallas |
Iowa |
Jered Holker |
Wes Duncan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ryan Shabino |
ryan@prdgmgroup.com |
Owner |
Cumming |
Madison |
Iowa |
Wes Duncan |
Jered Holker |
Signed |
759 |
2023-08-31 16:11 |
Anonymous (not verified) |
94.188.207.230 |
Living Free Ministries |
11 2nd St NW, Mason City, IA 50401 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-31 |
Jani Dahlin |
livingfreeiowa@gmail.com |
Mason City |
Cerro Gordo |
IA |
Jenny McIntyre |
Alex Meier |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jani Dahlin |
livingfreeiowa@gmail.com |
President |
Mason City |
Cerro Gordo |
IA |
Jenny McIntyre |
Alex Meier |
Signed |
758 |
2023-08-29 11:56 |
Anonymous (not verified) |
94.188.207.229 |
Ellison building and repair |
2722 645th moravia IA 52571 |
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. |
2023-08-18 |
Keeton Ellison |
keeton2005@gmail.com |
Moravia |
Appanoose |
Iowa |
Cory Ellison |
Sammy Ellison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sammy Ellison |
sammyllsn@yahoo.com |
Mom |
Moravia |
Monroe |
Iowa |
Cory Ellison |
Sammy Ellison |
Signed |
757 |
2023-08-28 12:11 |
Anonymous (not verified) |
94.188.207.230 |
J.R. Stelzer Co |
5850 Russell Dr. Lincoln, NE 68507 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-28 |
Mike Stelzer |
mike@jrstelzer.com |
Lincoln |
NE |
United States |
Bill Stelzer |
Jim Stelzer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mike Stelzer |
mike@jrstelzer.com |
President |
Lincoln |
Lancaster |
NE |
Bill Stelzer |
Jim Stelzer |
Signed |
756 |
2023-08-28 09:10 |
Anonymous (not verified) |
94.188.205.177 |
J.R. Stelzer Co. |
5850 Russell Dr Ste 1, Lincoln, NE 68507 |
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. |
2023-07-01 |
William James Stelzer |
bill@jrstelzer.com |
Lincoln |
Nebraska |
United States |
Michael G Stelzer |
Marcia Brouillette |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William James Stelzer |
bill@jrstelzer.com |
Officer |
Lincoln |
Lancaster |
NE |
Michael G. Stelzer |
Marcia Brouillette |
Signed |
755 |
2023-08-25 11:34 |
Anonymous (not verified) |
94.188.205.169 |
Paralax Corporation dba Beck Electric |
8646 103rd Ave Indianola Iowa 50125 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-25 |
Jonathan Beck |
jon@beck-electric.com |
Indianola |
Warren |
Iowa |
Stephanie Watkins-Beck |
Michael Beck |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jonathan Beck |
jon@beck-electric.com |
Owner |
Indianola |
Warren |
Iowa |
Stephanie Watkins-Beck |
Michael Beck |
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 |
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 |
752 |
2023-08-21 14:04 |
Anonymous (not verified) |
94.188.205.177 |
Johnson Custom Paint and Design, LLC |
1414 N 9th street Fort Dodge Iowa 50501 |
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 |
Joshua Johnson |
jackiejohnson1251@gmail.com |
Fort dodge |
Webster |
Iowa |
Jacklyn Johnson |
Roger Johnson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jacklyn Johnson |
jackiejohnson1251@gmail.com |
Wife |
Fort dodge |
Webater |
Iowa |
Jacklyn Johnson |
Roger Johnson |
Signed |
751 |
2023-08-21 09:18 |
Anonymous (not verified) |
94.188.205.168 |
Johnson Custom Paint and Design LLC DBA Mid-century Sign Company |
1414 N 9th street Fort Dodge, Iowa 50501 |
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 |
Joshua Johnson |
johnsoncustompaint@hotmail.com |
Fort Dodge |
Webster |
Iowa |
Jacklyn Johnson |
Roger Johnson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joshua Johnson |
johnsoncustompaint@hotmail.com |
Owner |
Fort Dodge |
webster |
Iowa |
Jacklyn Johnson |
Roger Johnskn |
Signed |
750 |
2023-08-20 16:41 |
Anonymous (not verified) |
94.188.207.229 |
Wonderfully Made LLC |
2003 Downing Ave Waterloo IA 50701 |
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. |
2023-08-20 |
Alexis Lise Martinez |
victorandleximartinez@gmail.com |
Waterloo |
Black Hawk |
IA |
Trey Patterson |
Lauren Shaff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Alexis Lise Martinez |
victorandleximartinez@gmail.com |
Owner |
Waterloo |
Black Hawk |
IA |
Trey Patterson |
Lauren Shaff |
Signed |
749 |
2023-08-20 16:36 |
Anonymous (not verified) |
94.188.207.225 |
Wonderfully Made LLC |
2003 Downing Ave Waterloo IA 50701 |
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. |
2023-08-20 |
Víctor Manuel Martinez Jr. |
martinezvic54@gmail.com |
Waterloo |
Black Hawk |
IA |
Trey Patterson |
Lauren Shaff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Alexis Lise Martinez |
victorandleximartinez@gmail.com |
Owner |
Waterloo |
Black Hawk |
IA |
Trey Patterson |
Lauren Shaff |
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 |
747 |
2023-08-19 15:30 |
Anonymous (not verified) |
94.188.207.229 |
Arneson Tree Service |
901 s Washington st Lake Mills IOWA 50450 |
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. |
2023-08-19 |
Charles Douglas Arneson |
charles.arneson@aol.com |
Lake Mills |
Winnebago |
IOWA |
Amber Arneson |
Carter Arneson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Charles Douglas Arneson |
charles.arneson@aol.com |
Owner |
Lake Mills |
Winnebago |
IOWA |
Amber arneson |
Carter Arneson |
Signed |
746 |
2023-08-17 11:31 |
Anonymous (not verified) |
94.188.207.225 |
NIEMEYER WELL AND PUMP INC |
2735 GARFIELD AVE, HULL IA 51239 |
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. |
2023-08-15 |
ELIJAH NIEMEYER |
PERSONALELINIEMEYER@GMAIL.COM |
HULL |
SIOUX |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ELIJAH NIEMEYER |
PERSONALELINIEMEYER@GMAIL.COM |
SELF |
HULL |
SIOUX |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
745 |
2023-08-17 11:29 |
Anonymous (not verified) |
94.188.207.226 |
NIEMEYER WELL AND PUMP INC |
2735 GARFIELD AVE, HULL IA 51239 |
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. |
2023-08-11 |
HAROLD NIEMEYER |
handmpump@gmail.com |
FREEMAN |
HUTCHINSON |
SD |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
HAROLD NIEMEYER |
handmpump@gmail.com |
SELF |
FREEMAN |
HUTCHINSON |
SD |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
744 |
2023-08-17 11:25 |
Anonymous (not verified) |
94.188.207.225 |
NIEMEYER WELL AND PUMP INC |
2735 GARFIELD AVE, HULL IA 51239 |
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. |
2023-08-15 |
TYLER NIEMEYER |
neighborhoodpump@gmail.com |
CANTON |
LINCOLN |
SD |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
TYLER NIEMEYER |
neighborhoodpump@gmail.com |
SELF |
CANTON |
LINCOLN |
SD |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
743 |
2023-08-15 15:03 |
Anonymous (not verified) |
94.188.205.177 |
R & T Trucking LLC |
1374 Creamery Road, Afton Iowa 50830 |
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. |
2023-08-15 |
Robert Dike |
robandteenadike@outlook.com |
Afton |
Union |
Iowa |
Kristina Dike |
Robert Dike |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Dike |
robandteenadike@outlook.com |
Owner |
Afton |
Union |
Iowa |
Kristina Dike |
Robert Dike |
Signed |
742 |
2023-08-15 12:06 |
Anonymous (not verified) |
94.188.205.175 |
The Ritz Restaurant, LLC |
232 1st Ave E - Dyersville, IA 52040 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-11 |
Dan Engstrom |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
jheims@english-insurance.com |
self |
Dyersville |
IA |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
741 |
2023-08-15 12:03 |
Anonymous (not verified) |
94.188.205.176 |
The Ritz Restaurant, LLC |
232 1st Ave E - Dyersville, IA 52040 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-11 |
Megan Engstrom |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
jheims@english-insurance.com |
self |
Dyersville |
DUbuque |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
740 |
2023-08-14 10:25 |
Anonymous (not verified) |
94.188.205.167 |
Absolute Mud Jacking Inc |
5038 Brittany Ct 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. |
2023-08-12 |
Paul Pelzer |
pelzer830@gmail.com |
Bettendorf |
IA |
United States |
Brett Lewandowski |
Phil Schaefer |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Pelzer |
pelzer830@gmail.com |
Owner |
Bettendorf |
IA |
United States |
Brett Lewandowski |
Phil Schaefer |
Signed |
739 |
2023-08-11 18:02 |
Anonymous (not verified) |
94.188.205.176 |
Frontline Roofing & Construction LLC |
310 W Gilbert 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. |
(2) I decline to reject the employer’s liability coverage. |
2023-08-10 |
Verónica Santos |
FrontlineR-C@outlook.com |
Evansdale |
BlackHawk County |
IA |
Angela Hernandez |
Kevi Hernandez |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Veronica Santos |
angelasermeno@gmail.com |
Owner |
Evansdale |
BlackHawk |
IA |
Angela |
Hernandez |
Signed |
738 |
2023-08-11 08:47 |
Anonymous (not verified) |
94.188.207.223 |
Infrastructure Engineering, Inc. |
1451 NE 69TH PL, Ste 42 Ankeny, IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-11 |
Joel Peiffer |
peifferj@ieidsm.com |
Ankeny |
Polk |
Iowa |
Bret Larkins |
Heather Cornwell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joel Peiffer |
peifferj@ieidsm.com |
Owner |
ANKENY |
Iowa |
Iowa |
Bret Larkins |
Heather Cornwell |
Signed |
737 |
2023-08-10 21:39 |
Anonymous (not verified) |
94.188.207.224 |
fixIT.fyi, LLC |
1243 Buchanan Ave, Sioux City, IA 51108 |
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. |
2023-08-10 |
Daisy Larae Neuroth |
Daisy@fixIT.fyi |
Sioux City |
Woodbury |
Iowa |
Chad Neuroth |
Alice Bruns |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daisy Larae Neuroth |
Daisy@fixIT.fyi |
Owner/Same |
Sioux City |
Woodbury |
Iowa |
Chad Neuroth |
Alice Bruns |
Signed |
736 |
2023-08-10 11:28 |
Anonymous (not verified) |
94.188.205.169 |
Johnson Custom Paint & Design |
1414 N 9th st |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-10 |
Joshua Johnson |
johnsoncustompaint@hotmail.com |
Fort Dodge |
Webster |
Iowa |
Jacklyn Johnson |
Roger Johnson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joshua Johnson |
johnsoncustompaint@hotmail.com |
Owner |
Fort Dodge |
Webster |
Iowa |
Jacklyn Johnson |
Roger Johnson |
Signed |
735 |
2023-08-10 08:07 |
Anonymous (not verified) |
94.188.205.166 |
GIBSON CLOVER HOUSE LLC |
601 South roosevelt suite 101 |
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. |
2023-08-10 |
Zacary Richard Gayewski |
zgay187@outlook.com |
BURLINGTON |
Des Moines |
Iowa |
John Jacob gayewski |
Derek Wayne Shipley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Jacob Gayewski |
zgay187@outlook.com |
owner |
burlington |
Des Moines |
Iowa |
Zacary Richard Gayewski |
Derek Wayne Shipley |
Signed |
734 |
2023-08-09 10:33 |
Anonymous (not verified) |
94.188.207.227 |
Atcher Service LLC |
145 Fremont Street, Hartford, IA 50118 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-08 |
Mandalena K Love |
dlovem2002@gmail.com |
Hartford |
Warren |
Iowa |
Dan Love |
Michael Love |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel J Love |
atcherservicetowing@gmail.com |
owner |
Hartford |
Warren |
Iowa |
Dan Love |
Michael Love |
Signed |
733 |
2023-08-09 10:22 |
Anonymous (not verified) |
94.188.207.230 |
Atcher Service LLC |
145 Fremont Street, Hartford, IA 50118 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-08-08 |
Daniel J Love |
atcherservicetowing@gmail.com |
Hartford |
Warren |
Iowa |
Mandy Love |
Michael Love |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mandy Love |
dlovem2002@gmail.com |
owner |
Hartford |
Warren |
Iowa |
Dan Love |
Michael Love |
Signed |
732 |
2023-08-07 10:04 |
Anonymous (not verified) |
94.188.207.223 |
Troy Neville |
3647 Dean Ave. Odebolt, IA 51458 |
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. |
2023-08-07 |
Troy Leslie Neville |
neville@schallertel.net |
Odebolt |
Sac |
Iowa |
Joe McCollum |
Heather Husman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Troy Neville |
neville@schallertel.net |
onwer |
Odebolt |
Sac |
Iowa |
Joe McCollum |
Heather Husman |
Signed |
731 |
2023-08-04 09:43 |
Anonymous (not verified) |
94.188.207.229 |
Hopp's Computers & More |
855 S. Page St., Nauvoo, IL 62354 |
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. |
2023-08-04 |
James Hopp |
tech@hoppcomputers.com |
Nauvoo |
Hancock |
Illinois |
Carol McGhghy |
Ana LeVesque |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Hopp |
tech@hoppcomputers.com |
Owner |
Nauvoo |
Hancock |
Illinois |
Carol McGhghy |
Ana LeVesque |
Signed |
730 |
2023-08-04 07:42 |
Anonymous (not verified) |
94.188.207.225 |
Barrel Head Winery Inc |
9995 Laudeville Road, Dubuque, IA 52003 |
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. |
2023-08-03 |
Jodie Fuhreck |
sales@barrelheadiowa.com |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jodie Fuhreck |
sales@barrelheadiowa.com |
Owner |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
729 |
2023-08-04 07:39 |
Anonymous (not verified) |
94.188.207.228 |
Barrel Head Winery Inc |
9995 Laudeville Road, Dubuque, IA 52003 |
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. |
2023-08-03 |
Aaron Fuhreck |
sales@barrelheadiowa.com |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Aaron Fuhreck |
sales@barrelheadiowa.com |
Owner |
Dubuque |
Dubuque |
Iowa |
Derrick Parsons |
Derrick Parsons |
Signed |
728 |
2023-08-03 12:28 |
Anonymous (not verified) |
94.188.205.166 |
Advanced Plumbing LLC |
2538 Carbide Ln, Keokuk, IA 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. |
2023-08-03 |
James O'Shea |
advancedplumbing1@yahoo.com |
Keokuk |
Iowa |
United States |
Rebecca O'Shea |
Tate O'Shea |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James O'Shea |
advancedplumbing1@yahoo.com |
Partner |
Keokuk |
Iowa |
United States |
Rebecca O'Shea |
Tate O'Shea |
Signed |
727 |
2023-08-02 18:25 |
Anonymous (not verified) |
94.188.205.176 |
Furever Friends Rescue of Appanoose, Inc |
19507 Hwy 2, Centerville, Iowa 52544 |
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. |
2023-08-02 |
Krystal Fowler |
krystalfowler@gmail.com |
Cincinnati |
Appanoose |
Iowa |
Jennifer Appler |
Kimberly Stonehouse |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Krystal Fowler |
krystalfowler@gmail.com |
Treasurer |
Cincinnati |
Appanoose |
Iowa |
Jennifer Appler |
Kim Stonehouse |
Signed |
726 |
2023-08-02 17:30 |
Anonymous (not verified) |
94.188.205.169 |
Furever Friends of Appanoose, Inc |
19507 Hwy 2, Centerville, Iowa 52544 |
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. |
2023-08-02 |
Clint Raymond Housh |
clinthoush@lockridgeinc.com |
Centerville |
Appanoose |
Iowa |
Brian Seeman |
Drew Power |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Clint Housh |
clinthoush@lockridgeinc.com |
Vice President |
Centerville |
Appanoose |
Iowa |
Brian Seeman |
Drew Power |
Signed |
725 |
2023-08-02 17:25 |
Anonymous (not verified) |
94.188.207.225 |
Furever Friends Rescue of Appanoose, Inc |
19507 Hwy 2, Centerville, Iowa 52544 |
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. |
2023-08-02 |
Dustin Cain Bozwell |
dcbozwell@gmail.com |
Centerville |
Appanoose |
Iowa |
Kimberly Stonehouse |
Jennifer Appler |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dustin Bozwell |
dcbozwell@gmail.com |
President |
Centerville |
Appanoose |
Iowa |
Kimberly Stonehouse |
Jennifer Appler |
Signed |
724 |
2023-08-02 16:09 |
Anonymous (not verified) |
94.188.207.223 |
Magnussen Bros Inc |
1945 560th Street, Newell, IA 50568 |
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. |
2023-08-02 |
Duane Magnussen |
dcmag@ncn.net |
Newell |
Buena Vista |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Duane Magnussen |
ncmag@ncn.net |
Owner |
Newell |
Buena Vista |
IA |
Jared Brashears |
Katie Gunkelman |
Signed |