371 |
2021-12-09 11:03 |
Anonymous (not verified) |
216.81.176.153 |
Concentric International Inc. |
1901 Bell Ave Ste 18, Des Moines, IA 50315-1067 |
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. |
2021-12-09 |
Tracey Ball |
tball@ruan.com |
Urbandale |
IA |
United States |
Jackie Walker |
Craig Gesme |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Tracey Ball |
tball@ruan.com |
Treasurer |
Urbandale |
IA |
United States |
Jackie Walker |
Craig Gesme |
Signed |
428 |
2022-03-23 12:00 |
Anonymous (not verified) |
76.76.231.229 |
Connelly Sanitation Inc |
108 S. 14th St. Fairfield IA 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. |
2022-03-23 |
Richard Raymond Vogt |
connelly.inc@outlook.com |
Fairfield |
Jefferson |
Iowa |
Mindy Lynn Vogt |
Chester James Vogt |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Richard Raymond Vogt |
connelly.inc@outlook.com |
Self |
Fairfield |
Jefferson |
Iowa |
Mindy Lynn Vogt |
Chester James Vogt |
Signed |
798 |
2023-10-20 10:54 |
Anonymous (not verified) |
94.188.205.177 |
Connerley Construction Inc |
5915 4Th St. SW Cedar Rapids, Iowa 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-20 |
Allen Connerley |
betterrentalsbyconnerley@aol.com |
CEDAR RAPIDS |
Linn |
Iowa |
Nika Mefford |
Duane Anderson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Connerley Construction Inc |
Connerleyconstruction@gmail.com |
Owner |
Cedar Rapids |
Linn |
IA |
Nika Mefford |
Duane Anderson |
Signed |
896 |
2024-02-23 16:14 |
Anonymous (not verified) |
94.188.205.167 |
Convenience Stores Business Inc |
1615 Bishop Ave, Waterloo, IA 50707 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2025-02-26 |
John Sarwar |
trampride@aol.com |
Waterloo |
Black Hawk |
IA |
. |
. |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jason Koch |
jason_koch@veridiancu.org |
Agent |
Waterloo |
Black Hawk |
IA |
. |
. |
Signed |
464 |
2022-05-06 10:15 |
Anonymous (not verified) |
172.86.44.178 |
Cornhill Express LLC |
6472 40th St, Aurora, IA 50607 |
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. |
2022-05-06 |
Jamie Fettkether |
sales@cherepair.com |
Aurora |
Buchanan |
Iowa |
Ben Hogan |
Ryan Peyton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jamie Fettkether |
sales@cherepair.com |
Owner |
Aurora |
Buchanan |
Iowa |
Ben Hogan |
Ryan Peyton |
Signed |
575 |
2022-11-18 14:01 |
Anonymous (not verified) |
204.155.61.217 |
County Line Drainage Inc |
806 Milton Ave, Lake Mills, IA 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. |
2022-11-18 |
Brian Helgeson |
dgust@mbtbank.com |
Lake Mills |
Winnebago |
Iowa |
Douglas Gust |
Lee Lambert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brian Helgeson |
brianshelgeson@gmail.com |
President |
Lake mills |
Winnebago |
Iowa |
Douglas Gust |
Lee Lambert |
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 |
18 |
2019-12-16 14:00 |
Anonymous (not verified) |
206.80.132.15 |
Cresco Family Dentistry P.C. |
210 N Elm St Cresco, IA 52136 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-12-16 |
Jeffrey K Haw |
cfdentistry@iowatelecom.net |
Cresco |
Howard |
Iowa |
Don Dietzenbach |
Kim Holmes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey K Haw |
cfdentistry@iowatelecom.net |
President |
Cresco |
Howard |
Iowa |
Don Dietzenbach |
Kim Holmes |
Signed |
19 |
2019-12-16 14:04 |
Anonymous (not verified) |
206.80.132.15 |
Cresco Family Dentistry P.C. |
210 N Elm St Cresco, IA 52136 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-12-16 |
Shirlee J Haw |
cfdentistry@iowatelecom.net |
Cresco |
Howard |
Iowa |
Don Dietzenbach |
Kim Holmes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey K Haw |
cfdentistry@iowatelecom.net |
President |
Cresco |
Howard |
Iowa |
Don Dietzenbach |
Kim Holmes |
Signed |
512 |
2022-07-15 11:45 |
Anonymous (not verified) |
50.80.230.95 |
CRV, Inc |
1607 LaPorte Rd Waterloo, IA 50702 |
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. |
2022-07-15 |
Maureen Louise Corpman |
priorityone@thewebunwired.com |
Cedar Falls |
Black Hawk |
IA |
John W Vinton |
Stephen A Brustkern |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Maureen Louise Corpman |
priorityone@thewebunwired.com |
Officer |
Cedar Falls |
Black Hawk |
IA |
John W Vinton |
Stephen A Brustkern |
Signed |
513 |
2022-07-15 11:49 |
Anonymous (not verified) |
50.80.230.95 |
CRV, Inc |
1607 LaPorte Rd Waterloo, IA 50702 |
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. |
2022-07-15 |
Matthew Jason Corpman |
priorityone@thewebunwired.com |
Dysart |
Tama/Benton |
Iowa |
John W Vinton |
Stephen A Brustkern |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Matthew Jason Corpman |
priorityone@thewebunwired.com |
Officer |
Dysart |
Tama/Benton |
IA |
John W Vinton |
Stephen A Brustkern |
Signed |
514 |
2022-07-15 11:51 |
Anonymous (not verified) |
50.80.230.95 |
CRV, Inc |
1607 LaPorte Rd Waterloo, IA 50702 |
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. |
2022-07-15 |
Brett Allyn Corpman |
priorityone@thewebunwired.com |
Waterloo |
Black Hawk |
Iowa |
John W Vinton |
Stephen A Brustkern |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brett Allyn Corpman |
priorityone@thewebunwired.com |
Officer |
Waterloo |
Black Hawk |
IA |
John W Vinton |
Stephen A Brustkern |
Signed |
511 |
2022-07-15 11:41 |
Anonymous (not verified) |
50.80.230.95 |
CRV, INC. |
1607 LaPorte Rd Waterloo, IA 50702 |
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. |
2022-07-15 |
Leonard Wayne Corpman |
priorityone@thewebunwired.com |
Cedar Falls |
Black Hawk |
IA |
John W Vinton |
Stephen A Brustkern |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Leonard Wayne Corpman |
priorityone@thewebunwired.com |
Officer |
Cedar Falls |
Black Hawk |
IA |
John W Vinton |
Stephen A Brustkern |
Signed |
850 |
2024-01-11 15:22 |
Anonymous (not verified) |
94.188.205.167 |
CUB CONSTRUCTION LLC |
4243 GRANDVIEW AVE, DES MOINES, IOWA 50317 |
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. |
2024-01-11 |
SUSANA MELENDEZ |
melendezsusana342@gmail.com |
Des Moines |
Polk |
Iowa |
Elsa Villanueva |
Jaime Leiva |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Susana Melendez |
melendezsusana342@gmail.com |
Owner |
Des Moines |
Pok |
Iowa |
Elsa Villanueva |
Jaime Leiva |
Signed |
808 |
2023-11-08 07:37 |
Anonymous (not verified) |
94.188.207.229 |
Cush Comfort |
1225 e. River Dr STE 206 Davenport IA 52803 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-30 |
Chris Cushman |
ccushman82@gmail.com |
Milan |
IL |
United States |
Deena Maurus |
Jenna Ortberg |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher Cushman |
ccushman82@gmail.com |
Owner |
Milan |
IL |
United States |
Deena Maurus |
Jenna Ortberg |
Signed |
830 |
2023-12-03 18:42 |
Anonymous (not verified) |
94.188.205.167 |
Custom Decks, LLC |
5719 Washington Ave, Des Moines, IA 50310-1072 |
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. |
2023-12-03 |
Charles Dean Oakley IV |
oakleyoutdoorsolutions@gmail.com |
Carlisle |
Warren |
Iowa |
Sharon Marie Bracelin |
Casey John Eaton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Charles Dean Oakley IV |
Oakleyoutdoorsolutions@gmail.com |
Owner |
Carlisle |
Warren |
Iowa |
Casey John Eaton |
Sharon Marie Bracelin |
Signed |
858 |
2024-01-18 08:24 |
Anonymous (not verified) |
94.188.207.226 |
Custom Flooring LLC |
7085 Bloomfield Road Lot 249 Des Moines, Iowa 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-18 |
Jesus Vera |
jesusvera199027@icloud.com |
Des Moines |
Polk |
Iowa |
Natalia Vera |
Adriana de Anda |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jesus Vera |
jesusvera199027@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Natalia Vera |
Adriana de Anda |
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 |
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 |
450 |
2022-04-20 13:42 |
Anonymous (not verified) |
96.85.81.137 |
D&K Harvesting Inc. |
P.o Box 1347 LaBelle Fl 33975 |
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. |
2022-04-20 |
James Larry Marsh Jr |
larrym3041@aol.com |
Fort myers |
Lee |
Florida |
Anita Coronado |
Christy Pequeno |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
James Larry Marsh Jr |
larrym3041@aol.com |
Owner |
Fort myers |
Lee |
Florida |
Anita Coronado |
Christy Puequeno |
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 |
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 |
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 |
703 |
2023-06-27 07:05 |
Anonymous (not verified) |
94.188.207.229 |
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 |
Calvin Otundo |
calvin@dancoms.com |
Waukee |
Polk |
IA |
Joe Meyers |
Robert Simmons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Calvin Otundo |
calvin@dancoms.com |
Owner |
Waukee |
Polk |
IA |
Robert Simmons |
Joe Meyers |
Signed |
534 |
2022-09-09 08:35 |
Anonymous (not verified) |
192.95.125.128 |
Darri, Inc. |
903 W 4th Street, Vinton, IA 52349 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-09-09 |
Teri Jo Sellers |
teri@bobbinsandboards.com |
Vinton |
Benton |
Iowa |
Hanna Gregory |
Jennie Lynn Roster |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Darran Kenneth Sellers |
darran.sellers@mrhandyman.com |
President |
Vinton |
Benton |
Iowa |
Hanna Gregory |
Jennie Lynn Roster |
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 |
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 |
306 |
2021-08-11 17:03 |
Anonymous (not verified) |
208.73.53.194 |
Dave Sturges Trucking Inc |
16244 170th St. Rockwell, IA 50469 |
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. |
2021-08-11 |
Joseph d sturges |
sturgtrucking@gmail.com |
Rockwell, IA |
Cerro Gordo |
IA |
Connie Downing |
Darc Schropshire |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brian Sturges |
briansturges@netins.net |
President |
Rockwell, Ia |
Cerro Gordo |
IA |
Connie Downing |
Darc Schropshire |
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 |
984 |
2024-05-13 11:05 |
Anonymous (not verified) |
94.188.207.224 |
Davis County Fiberglass LLC |
20641 Old Highway 2, Bloomfield IA 52537 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-13 |
Ronald Simmons |
daviscountyfiberglass@gmail.com |
Drakesville |
Davis County |
Iowa |
Lisa Bell |
Lynn Bumsted |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Ronald Simmons |
daviscountyfiberglass@gmail.com |
Owner |
Drakesville |
Davis County |
Iowa |
Lisa Bell |
Lynn Bumsted |
Signed |
347 |
2021-10-14 19:28 |
Anonymous (not verified) |
75.162.50.106 |
Dawn's Daycare |
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 |
James J Stonehocker |
j_stonehocker@hotmail.com |
Earlham |
Madison |
iowa |
Anne Larson |
Alison Werts |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James J Stonehocker |
j_stonehocker@hotmail.com |
Owner |
Earlham |
Madison |
Iowa |
Anne Larson |
Alison Werts |
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 |
840 |
2023-12-18 16:21 |
Anonymous (not verified) |
94.188.205.166 |
DC Painting Inc |
205 Astor St |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-18 |
Damion Clement |
amanda_thompson_marie@yahoo.com |
Des Moines |
polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Damion Clement |
amanda_thompson_marie@yahoo.com |
owner |
Des Moines |
Polk |
IA |
Brandi Haight |
Amanda Thompson |
Signed |
622 |
2023-03-08 13:40 |
Anonymous (not verified) |
94.188.207.226 |
DDD Construction |
624 west maple P.O.164 Allerton |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-08 |
Douglas Dean Downs |
tripledconstruction@hotmail.com |
ALLERTON |
IA |
United States |
June Lynette Downs |
William Lee Downs |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Douglas Dean Downs |
tripledconstruction@hotmail.com |
Coowner |
ALLERTON |
IA |
United States |
June Lynette Downs |
William Lee Downs |
Signed |
119 |
2020-09-28 10:43 |
Anonymous (not verified) |
174.213.149.6 |
Ddp construction |
1923 63rd st, des moines ,ia 50322 |
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. |
2020-09-28 |
Dustin a perry |
perrythedustin@gmail.com |
Urbandale |
Polk |
Iowa |
Lucas jackson |
Cody roth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Smith Kenyon insurance |
smithkenyon@yahoo.com |
Agent |
Urbandale |
Polk |
Ia |
Lucas jackson |
Cody roth |
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 |
628 |
2023-03-21 12:07 |
Anonymous (not verified) |
94.188.207.226 |
Deep Cleaning Janitorial Inc |
3131 33rd Ave SW Ceder Rapids IA 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-21 |
Paul Mwai |
deepcleaning0142@gmail.com |
Cedar Rapids |
IA |
United States |
Mary Ngotho |
John Johnson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ray Robertson |
deepcleaning0142@gmail.com |
Co-Owner |
Cedar Rapids |
Linn |
United States |
John Johnson |
Mary Ngotho |
Signed |
629 |
2023-03-21 12:14 |
Anonymous (not verified) |
94.188.207.230 |
Deep Cleaning Janitorial Inc |
3131 33rd Ave SW Ceder Rapids IA 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-21 |
Ray Robertson |
deepcleaning0142@gmail.com |
Cedar Rapids |
linn |
United States |
Shelley Robertson |
William Robertson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Mwai |
deepcleaning0142@gmail.com |
Co-Owner |
Cedar Rapids |
Linn |
IA |
Shelley Robertson |
William Robertson |
Signed |
650 |
2023-04-10 13:06 |
Anonymous (not verified) |
94.188.205.168 |
Deep Cleaning Janitorial Inc |
3131 33rd Ave SW Ceder Rapids IA 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-11 |
Paul Mwai |
deepcleaning0142@gmail.com |
Cedar Rapids |
IA |
United States |
Mary Ngotho |
John Johnson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ray Robertson |
deepcleaning0142@gmail.com |
Co-Owner |
Cedar Rapids |
Linn |
United States |
Shelley Robertson |
William Robertson |
Signed |
651 |
2023-04-10 13:21 |
Anonymous (not verified) |
94.188.205.175 |
Deep Cleaning Janitorial Inc |
3131 33rd Ave SW Ceder Rapids IA 52404 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-04-10 |
Ray Robertson |
deepcleaning0142@gmail.com |
Cedar Rapids |
IA |
United States |
Shelley Robertson |
William Robertson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Paul Mwai |
deepcleaning0142@gmail.com |
Co-Owner |
Cedar Rapids |
Linn |
United States |
Mary Ngotho |
John Johnson |
Signed |
918 |
2024-03-11 14:29 |
Anonymous (not verified) |
94.188.207.224 |
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 |
Marvin L. DeJear Jr |
marvin.dejear@gmail.com |
Des Moines |
Polk |
Iowa |
Rory Robson |
Geoff Matlock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marvin L. DeJear Jr |
dejear@dejearcorporation.com |
Chief Administrative Officer |
Des Moines |
Polk |
Iowa |
Rory Robson |
Geoff Matlock |
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 |
388 |
2022-01-11 13:58 |
Anonymous (not verified) |
184.80.177.137 |
Demmer Construction |
203 Michigan Ave - Farley, IA 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. |
2021-12-21 |
Charlie Demmer |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jenny Osburn |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
389 |
2022-01-11 14:02 |
Anonymous (not verified) |
184.80.177.137 |
Demmer Construction |
203 Michigan Ave - Farley, IA 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. |
2021-05-12 |
Charlie Demmer |
jheims@english-insurance.com |
Farley |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jenny Osburn |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
229 |
2021-04-05 13:44 |
Anonymous (not verified) |
173.18.193.51 |
Denmark Sanitary District |
PO Box 141, Denmark, Iowa 52624 |
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 |
Clay Fullenkamp |
judy@fullenkampins.com |
West Point |
Lee |
Iowa |
Judy Moeller |
Brian Stuekerjuergen |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Clay Fullenkamp |
judy@fullenkampins.com |
Board Member |
West Point |
Lee |
Iowa |
judy moeller |
brian stuekerjuergen |
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 |
701 |
2023-06-22 15:06 |
Anonymous (not verified) |
94.188.205.166 |
Des Moines Contractors |
833 Buchanan st Des Moines ia 50316 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-22 |
Maison Wayne Miller |
DesMoinesContractors@gmail.com |
Des Moines |
Polk |
Iowa |
Kent Sorenson |
Krista Sheriff |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Maison Wayne Miller |
DesMoinescontractors@gmail.com |
Owner |
Des moines |
IA |
United States |
Kent Sorenson |
Krista Sheriff |
Signed |
685 |
2023-06-15 12:30 |
Anonymous (not verified) |
94.188.205.168 |
Des Moines Marble & Mantel Co. Inc. |
1507 Ohio Street Des Moines, IA 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-15 |
Benjamin Campos Rojas |
caya05rojas@gmail.com |
Des Moines |
Polk county |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mario DeMarco |
sandyatdmmarble@aol.com |
Owner |
Des Moines |
Polk County |
Iowa |
Erica Antonio Maya |
Ana Antonio Maya |
Signed |
686 |
2023-06-15 21:36 |
Anonymous (not verified) |
94.188.207.229 |
Des Moines Marble & Mantel Co.Inc. |
1507 Ohio Street Des Moines, IA 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-15 |
Ezequiel Campos Rojas |
Zequiel.11campos@gmail.com |
Des Moines |
POLK |
IOWA |
Daysi Campos Gaytan |
Rosalba Soto Hernandez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mario DeMarco |
sandyatdmmarble@aol.com |
Owner |
Des Moines |
Polk |
iowa |
Daysi Campos Gaytan |
Rosalba Soto Hernandez |
Signed |