499 |
2022-06-22 03:40 |
Anonymous (not verified) |
64.251.168.116 |
VALBURG AERIAL SPRAYING INC. |
27656 SD Hwy 44 WHITE RIVER SD 57579 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-19 |
Dan A Valburg |
agflyer620@gwtc.net |
White River |
SD |
SD |
LANDON HOSSLE |
JOSH HICKS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dan A Valburg |
agflyer620@gwtc.net |
PRESIDENT |
White River |
SD |
SD |
LANDON HOSSLE |
JOSH HICKS |
Signed |
144 |
2020-12-04 12:02 |
Anonymous (not verified) |
184.80.177.137 |
Arlen, LLC |
322 6th St SE - Dyersville, Iowa 52040 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-04 |
Dan Arlen |
jheims@english-insurance.com |
Dyersville |
IA |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joyce Heims |
joyce.heims1@gmail.com |
agent |
Dyersville |
IA |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
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 |
310 |
2021-08-16 10:37 |
Anonymous (not verified) |
71.86.215.206 |
st ansgar historic school project, inc |
po box 52 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-16 |
dana wold |
dawold@woldinc.com |
st ansgar |
mitchell |
ia |
julie thome |
dale blakestad |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
tyler mckinley |
tbmckinley@gmail.com |
treasurer |
rochester |
olmsted |
mn |
julie thome |
dale blakestad |
Signed |
801 |
2023-10-25 08:32 |
Anonymous (not verified) |
94.188.205.177 |
CEM Businesses LLC |
608 Evergreen Cir NW Bondurant, IA 50035 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-25 |
Dane McDonald |
danemcdonald2@gmail.com |
Bondurant |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dane McDonald |
dane.mcdonald@stellar-solar.net |
Self |
Bondurant |
Polk |
Iowa |
Raelynn Aicher |
Cameron VanBuren |
Signed |
239 |
2021-04-16 08:28 |
Anonymous (not verified) |
66.43.227.177 |
Zern Farm Corp |
15109 330th St. Conrad, IA 50621 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-03 |
Danice Zern |
nicole.stone@gnbins.com |
Conrad |
Grundy |
Iowa |
Nicole Stone |
Jeff Beeghly |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Danice Zern |
nicole.stone@gnbins.com |
Treasurer |
Conrad |
Grundy |
Iowa |
Nicole Stone |
Jeff Beeghly |
Signed |
558 |
2022-10-17 09:25 |
Anonymous (not verified) |
67.22.198.94 |
Baker Irrigation Inc. |
2621 310th St. Rock Valley, IA 51247 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-10-17 |
Daniel Baker |
dan@bakerirrigationia.com |
Rock Valley |
Sioux |
Iowa |
Jesse Niemeyer |
Crystal Brink |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Alex DeJager |
alex@bakerirrigationia.com |
Co-Owner |
Rock Valley |
Sioux |
Iowa |
Jesse Niemeyer |
Crystal Brink |
Signed |
555 |
2022-10-06 17:48 |
Anonymous (not verified) |
67.22.198.94 |
Baker Irrigation inc |
2621 310th 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. |
2022-10-08 |
Daniel Brent Baker |
dan@bakerirrigationia.com |
ROCK VALLEY |
IA |
United States |
Adam Kooistra |
Alex De Jager |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Baker |
dan@bakerirrigationia.com |
President |
ROCK VALLEY |
IA |
United States |
Alex DeJager |
Adam Kooistra |
Signed |
333 |
2021-09-14 14:53 |
Anonymous (not verified) |
147.0.156.50 |
O'Danny Boy Builders, Inc. |
7512 S. County Line Rd., Suite #4, Burr Ridge, IL 60527 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-14 |
Daniel Flanagan |
jflanagan@odannyboybuilders.com |
LaGrange |
Cook |
Illinois |
John Flanagan |
Mark Hayes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Flanagan |
Jflanagan@odannyboybuilders.com |
Executive |
Western Springs |
Cook |
IL |
Ben Weed |
Mark Hayes |
Signed |
586 |
2022-12-16 15:53 |
Anonymous (not verified) |
184.184.197.146 |
Halide Biologics |
330 Golfview Ave, Iowa City IA 52246 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-12-15 |
Daniel Infield |
danielinfield@gmil.com |
Bennington |
Douglas |
Nebraska |
Alexander Estell |
Jesse Herrera |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Infield |
danielinfield@gmail.com |
President |
Bennington |
NE |
United States |
Alexander Estell |
Jesse Herrera |
Signed |
963 |
2024-04-29 17:42 |
Anonymous (not verified) |
94.188.207.227 |
Total Construction Inc |
4607 S Ridge Rd Sioux City IA 51106 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-29 |
Daniel J Jennett II |
dj_jennett@hotmail.com |
Sioux City |
Woobury |
IA |
Julia L Lesko |
Olivia J Lesko |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel J Jennett II |
dj_jennett@hotmail.com |
President |
Sioux City |
Woodbury |
IA |
Julia L Lesko |
Olivia J Lesko |
Signed |
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 |
491 |
2022-06-06 09:32 |
Anonymous (not verified) |
24.118.76.144 |
Minnesota Restoration Contractors Inc. DBA MNRC |
12252 Nicollet Ave Burnsville, MN 55337 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-06 |
Daniel Lewis Lillestol |
info@mnrcinc.com |
Wayzata |
MN |
United States |
Karina Bazhenova |
MICHELLE LILLESTOL |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Lewis Lillestol |
info@mnrcinc.com |
CEO |
Wayzata |
Hennnepin |
MN |
Karina Bazhenova |
MICHELLE LILLESTOL |
Signed |
702 |
2023-06-27 07:04 |
Anonymous (not verified) |
94.188.207.230 |
Dancom Inc |
1001 Office Park Rd, West Des Moines, IA 50265 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-26 |
Daniel Otundo |
daniel@dancoms.com |
Waukee |
Polk |
IA |
Joe Meyers |
Robert Simmons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Otundo |
daniel@dancoms.com |
Owner |
Waukee |
Polk |
IA |
Robert Simmons |
Joe Meyers |
Signed |
139 |
2020-11-24 15:45 |
Anonymous (not verified) |
174.219.2.33 |
Dan Petersen Construction LLC |
1725 South 14th St, Polk City, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-11-24 |
Daniel Petersen |
danpetersenconstruction@gmail.com |
Polk City |
Polk |
Iowa |
Erik Gramenz |
Jim McMurray |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Petersen |
danpetersenconstruction@gmail.com |
Owner |
Polk City |
Polk |
Iowa |
Erik Gramenz |
Jim McMurray |
Signed |
328 |
2021-09-08 08:31 |
Anonymous (not verified) |
97.125.157.23 |
Dan Petersen Construction |
1725 S 14th St, Polk City, IA 50026 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-08 |
Daniel Petersen |
danpetersenconstruction@gmail.com |
Polk City |
Polk County |
Iowa |
Jim McMurray |
Erik Gramenz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Petersen |
danpetersenconstruction@gmail.com |
Owner |
Polk City |
Polk |
Iowa |
Jim McMurray |
Erik Gramenz |
Signed |
40 |
2020-02-14 09:22 |
Anonymous (not verified) |
50.83.38.221 |
Pa's Construction LLC |
2350 Glass RD NE |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-14 |
Daniel Saunders |
dan2112411@yahoo.com |
Cedar Rapids |
USA_IA |
USA_IA |
Walt Cheney |
Becky Cheney |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Saunders |
dan2112411@yahoo.com |
Owner- Manager |
Cedar Rapids |
USA_IA |
USA_IA |
Walt Cheney |
Becky Cheney |
Signed |
354 |
2021-11-04 16:26 |
Anonymous (not verified) |
97.64.194.58 |
D&D Construction |
1124 West Donald ST, Waterloo IA 50703 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-11-04 |
Darrel Caldwell |
dcaldwell1124@yahoo.com |
Waterloo |
Black Hawk County |
IA |
Scott Joseph Demuth |
Catrese Caldwell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
NA |
dcaldwell1124@yahoo.com |
NA |
NA |
NA |
NA |
NA |
NA |
Signed |
660 |
2023-04-26 07:56 |
Anonymous (not verified) |
94.188.207.227 |
Darrin Hearn DBA GoodCauseMinis |
445 Onyx Ave Marion IA 52302 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-26 |
Darrin Hearn |
goodcauseminis@gmail.com |
Marion |
IA |
United States |
Darrin Hearn |
Darrin Hearn |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Darrin Hearn |
goodcauseminis@gmail.com |
owner |
Marion |
IA |
United States |
Darrin Hearn |
Darrin Hearn |
Signed |
591 |
2023-01-22 11:19 |
Anonymous (not verified) |
216.106.211.176 |
Trackside Service & Repair Inc. |
205 Main St. Alvord, IA 51230 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-01-22 |
Darwyn G Klarenbeek |
trackside@alliancecom.net |
Rock Rapids |
Lyon |
United States |
Steve Green |
Renee Klarenbeek |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Darwyn G Klarenbeek |
trackside@alliancecom.net |
Owner |
Rock Rapids |
IA |
United States |
Steve C. Green |
Renee J Klarenbeek |
Signed |
934 |
2024-03-24 19:23 |
Anonymous (not verified) |
94.188.207.230 |
Dave Mckee |
3261 old river rd sw Cedar Rapids Ia 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-23 |
Dave mckee |
wildride1969@gmail.com |
Cedar Rapids |
Lynn |
Ia |
Dave mckee |
Valerie mckee |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave mckee |
wildride1969@gmail.com |
Owner |
Cedar Rapids |
Lynn |
Ia |
David mckee |
Valerie mckee |
Signed |
95 |
2020-07-02 10:30 |
Anonymous (not verified) |
206.125.132.254 |
Dave Prochaska Construction |
5848 Hopeview Ct |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-02 |
Dave Prochaska |
kschepers@nelsonbrothersagency.com |
Bettendorf |
Scott |
IA |
Kaitlin Schepers |
Lori Fisher |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave Prochaska |
kschepers@nelsonbrothersagency.com |
Owner |
Bettendorf |
Scott |
IA |
Kaitlin Schepers |
Lori Fisher |
Signed |
509 |
2022-07-05 13:51 |
Anonymous (not verified) |
96.31.7.128 |
KROESE CONSTRUSTION INC. |
822 7TH STREET |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-06 |
DAVID A KROESE |
dkkroese@hotmail.com |
Hull |
Sioux |
Iowa |
MATTHEW ROETMAN |
JOYCE VANDER WELL |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
SCOTT I KROESE |
scottkroese@hotmail.com |
vice president |
HULL |
SIOUX |
IOWA |
MATTHEW ROETMAN |
JOYCE VANDER WELL |
Signed |
257 |
2021-05-05 14:36 |
Anonymous (not verified) |
208.38.228.41 |
NSENSE inc |
415 Stanton Ave. Suite 205 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-05 |
David A. Laird |
dalaird@n-sense.us |
Ames |
Story |
IA |
Raina Powell |
Josh Powell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Laird |
dalaird@n-sense.us |
President |
Ames |
Story |
IA |
Besta Pruski |
Marek Pruski |
Signed |
269 |
2021-05-25 20:25 |
Anonymous (not verified) |
174.71.12.114 |
The Town and Country Aqua Club of Council Bluffs |
15444 Cherry Tree Lane Council Bluffs, Iowa 51503 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-25 |
David Alan Bergman |
dbrgmn@gmail.com |
Council Bluffs |
Iowa |
United States |
Brett Ford |
Sean Dunphy |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Alan Bergman |
dbrgmn@gmail.com |
Board Vice President |
Council Bluffs |
Iowa |
United States |
Brett Ford |
Sean Dunphy |
Signed |
500 |
2022-06-22 15:55 |
Anonymous (not verified) |
206.125.132.254 |
Cozad Trucking Inc |
2272 W River Dr, Davenport, IA 52802 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-22 |
David Cozad |
jeepd856@gmail.com |
Davenport |
Scott |
Iowa |
Brett Nelson |
Colleen Heiser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Cozad |
jeepd856@gmail.com |
Owner |
Davenport |
Scott |
IA |
Brett Nelson |
Colleen Heiser |
Signed |
944 |
2024-04-03 16:51 |
Anonymous (not verified) |
94.188.205.166 |
Butcher Insurance & Financial Services, Inc. |
220 5th Ave S Clinton, IA 52732 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-03 |
David E Butcher |
dave.butcher.efmk@statefarm.com |
Galena |
JoDaviess |
Illinois |
Sabra Petersen |
Klark Sikkema |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Butcher |
dave.butcher.efmk@statefarm.com |
President |
Galena |
JoDaviess |
Illinois |
Sabra Petersen |
Klark Sikkema |
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 |
46 |
2020-03-10 10:26 |
Anonymous (not verified) |
204.141.214.180 |
Shamrock Screenprinting Inc |
2710 Granite Ct NE |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-03-10 |
David Handley |
davehandley53@gmail.com |
Cedar Rapids |
Linn |
IA |
Lori Handley |
Beth Barta |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lori Handley |
Lori.handley@aol.com |
VP |
Cedar Rapids |
Linn |
IA |
Lori Handley |
Beth Barta |
Signed |
220 |
2021-03-29 08:07 |
Anonymous (not verified) |
173.18.193.51 |
Lee County Fair, Inc |
PO Box 179, Donnellson, 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. |
2021-03-23 |
David Hoenig |
judy@fullenkampins.com |
Fort Madison |
Lee |
Iowa |
Lindsey Lampe |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Hoenig |
judy@fullenkampins.com |
Board member |
Fort Madison |
Lee |
Iowa |
Lindsey Lampe |
Judy Moeller |
Signed |
28 |
2020-01-07 14:23 |
Anonymous (not verified) |
204.155.62.177 |
Money Handling Machines |
PO Box 34218, Omaha NE 68134-0128 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2020-01-01 |
David Jame Grimes |
daveg@moneyhandlingmanchines.com |
Omaha |
Douglas |
Nebraska |
Michael Bowman |
Joy Nickolte |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David James Grimes |
daveg@moneyhandlingmachines.com |
President |
Omaha |
Douglas |
NE |
Michael Bowman |
Joy Nickolite |
Signed |
459 |
2022-04-29 08:49 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West ave Baxter. IA 50028 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-02-15 |
David Kirkman |
kirkcola@gmail.com |
Newton |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rick Thatcher |
rickswrecks@gmail.com |
President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
320 |
2021-08-24 10:49 |
Anonymous (not verified) |
67.55.159.231 |
DL Johnson Company |
48600 Highway 64 Miles, IA 52064 |
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. |
2020-08-24 |
David Lee Johnson |
djohnson7_8@hotmail.com |
Miles |
Jackson |
Iowa |
Jeremy Sullivan |
Mitch Crockett |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Johnson |
Djohnson7_8@hotmail.com |
owner/manager |
Miles |
Jackson |
Iowa |
Jeremy Sullivan |
Mitch Crockett |
Signed |
940 |
2024-04-03 07:49 |
Anonymous (not verified) |
94.188.205.167 |
Wildride Trucking |
3261 old river rd sw. Cedar Rapids Ia |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-04-03 |
David mckee |
wildride1969@gmail.com |
Cedar Rapids |
Lynn |
Ia |
Valerie mckee |
Dillon Williams |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave mckee |
wildride1969@gmail.com |
Owner |
Cedar Rapids |
Lynn |
Ia |
Valerie mckee |
Dillon Williams |
Signed |
88 |
2020-06-10 11:36 |
Anonymous (not verified) |
173.28.7.32 |
DMG INSTALLATIONS INC |
5534 NE 17TH ST #4 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-06-10 |
DAVID PAUL DUNLAP |
HAYDAVE@AOL.COM |
DES MOINES |
POLK |
IOWA |
JASON DAVID MUSSO |
CLIFFORD LEE BAKER |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CLIFF BAKER |
CLBAKER@MEDIACOMBB.NET |
PRESIDENT |
ALTOONA |
POLK |
IOWA |
JASON DAVID MUSSO |
DAVID PAUL DUNLAP |
Signed |
305 |
2021-08-08 17:02 |
Anonymous (not verified) |
24.119.190.239 |
Shawn Smalls Painting Inc |
2736 South Cedar Street, Sioux City, IA 51106 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-08-08 |
David Shawn Small |
smallspaintingsc@gmail.com |
Sioux City |
Woodbury |
Iowa |
Douglas Wiliam Ball |
Ruth Elaine Ball |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Shawn Small |
smallspaintingsc@gmail.com |
Owner |
SIoux City |
Woodbury |
Iowa |
Douglas William Ball |
Ruth Elaine Ball |
Signed |
324 |
2021-08-31 09:19 |
Anonymous (not verified) |
76.84.58.43 |
Dave's Lawn Care |
716 4th Ave Nebraska City NE68410 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-01 |
David Wilberger |
daveslawncare00@gmail.com |
NEBRASKA CITY |
NE |
United States |
Linda Bowers |
Thomas Hume |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Wilberger |
daveslawncare00@gmail.com |
owner |
Nebraska City |
Otoe |
NE |
Linda Bowers |
Thomas Hume |
Signed |
859 |
2024-01-19 06:38 |
Anonymous (not verified) |
94.188.205.166 |
D & G Communications |
405 1st Street N. Farley, Iowa 52046 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-19 |
David William Hirsch |
dngcomm@hotmail.com |
Farley |
Dubuque |
Iowa |
Gina Hirsch |
Micki Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dave Hirsch |
dngcomm@hotmail.com |
Owner |
Farley |
Dubuque |
Iowa |
Gina Hirsch |
Micki Jones |
Signed |
346 |
2021-10-14 13:54 |
Anonymous (not verified) |
75.162.50.106 |
Dawn's Daycare & Educational Program |
360 NW Walnut Ave, Earlham, Iowa 50072 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-10-14 |
Dawn Lynnete Stonehocker |
daycare.dawn@gmail.com |
Earlham |
Madison |
Iowa |
Anne Marie Larson |
Alison Renae Werts |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dawn Lynnette Stonehocker |
daycare.dawn@gmail.com |
Self |
Earlham |
Madison |
Iowa |
Anne Marie Larson |
Alison Renae Werts |
Signed |
483 |
2022-06-02 08:28 |
Anonymous (not verified) |
173.18.193.51 |
Wever Fire Association |
1692 354th Avenue, Wever, Iowa 52658 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-24 |
Deb Sylvester |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Deb Sylvester |
judy@fullenkampins.com |
Secretary / Treasurer |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
657 |
2023-04-20 11:33 |
Anonymous (not verified) |
94.188.205.177 |
Debra Higgins |
201 Cedar 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. |
2023-04-20 |
Debra Higgins |
diggs0519@icloud.com |
Slater |
IA |
United States |
Howard Higgins |
Howard Higgins |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Debra Higgins |
diggs0519@icloud.com |
owner |
Slater |
IA |
United States |
Howard Higgins |
Howard Higgins |
Signed |
658 |
2023-04-20 11:39 |
Anonymous (not verified) |
94.188.205.167 |
Old Pros Consulting Inc |
201 Cedar St Slater Iowa 50244 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-20 |
Debra Higgins |
diggs0519@icloud.com |
Slater |
IA |
United States |
Howard Higgins |
Howard Higgins |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Debra Higgins |
diggs0519@icloud.com |
owner |
Slater |
IA |
United States |
Howard Higgins |
Howard Higgins |
Signed |
301 |
2021-08-04 10:05 |
Anonymous (not verified) |
63.142.48.170 |
Vision Homes Inc |
2566 Ivanhoe Rd. SW Cedar Rapids, IA 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-02 |
DeeAnn Nejdl |
chucknejdl@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Melanie Heitman |
Dan Lillis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
DeeAnn Nejdl |
chucknejdl@gmail.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Melanie Heitman |
Dan Lillis |
Signed |
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 |
919 |
2024-03-11 14:32 |
Anonymous (not verified) |
94.188.207.226 |
DeJear Inc. |
3220 SW 34th Street, Des Moines, Iowa 50321 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-03-11 |
Deidre Olivia DeJear |
deidre.dejear@gmail.com |
Des Moines |
Polk |
Iowa |
Rory Robson |
Geoff Matlock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marvin Leo DeJear Jr |
dejear@dejearcorporation.com |
Chief Administrative Officer |
Des Moines |
Polk |
Iowa |
Rory Robson |
Geoff Matlock |
Signed |
205 |
2021-03-10 09:55 |
Anonymous (not verified) |
173.27.221.9 |
Tri State Archery, Inc |
2100 White St, Dubuque IA 52001 |
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. |
2020-12-14 |
Denise Udelhofen |
office@tristateoutdoors.net |
Dubuque |
Dubuque |
Iowa |
Phillip J Meyer |
Debbie Meyer |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Jeff Udelhofen |
office@tristateoutdoors.net |
President |
Dubuque |
Dubuque |
IA |
Phillip Meyer |
Debbie Meyer |
Signed |
841 |
2023-12-18 16:28 |
Anonymous (not verified) |
94.188.205.168 |
Dennis Clement |
203 Astor St |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-18 |
Dennis Clement |
haight0929@gmail.com |
Des Moines |
Polk |
IA |
Amanda Thompson |
Brandi Haight |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dennis Clement |
haight0929@gmail.com |
none |
Des Moines |
polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
821 |
2023-11-17 13:30 |
Anonymous (not verified) |
94.188.207.230 |
ABC LOCK INC. |
2209 2nd Ave S. P.O. Box 433 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-17 |
Dennis Diekhuis |
keyman@cltel.net |
Clear Lake |
United States |
Iowa |
Dennis Diekhuis |
Dennis Diekhuis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dennis Diekhuis |
keyman@cltel.net |
Owner |
Clear lake |
United States |
Iowa |
Dennis Diekhuis |
Dennis Diekhuis |
Signed |
872 |
2024-01-26 10:28 |
Anonymous (not verified) |
94.188.205.177 |
Sole proprietor- Dennis R. Oliver dba Olivers Oasis Communications |
150 Spring Valley Ct. Springtown, TX 76082 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-26 |
Dennis Reeves Oliver |
doliversoasis@aol.com |
Springtown |
Parker |
Texas |
Helen Frances Steil |
John Kevin Steil |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dennis Reeves Oliver |
doliversoasis@aol.com |
Self |
Springtown |
Parker |
TX |
Helen Frances Steil |
John Kevin Steil |
Signed |
86 |
2020-06-03 17:56 |
Anonymous (not verified) |
75.162.69.231 |
Blackford Foundations Inc |
501 SW Franklin Dr, Ankeny, IA 50023 |
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. |
2020-05-01 |
Denny Lee Blackford |
blackfordfoundations@gmail.com |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Denny Lee Blackford |
blackfordfoundations@gmail.com |
Secretary |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |