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Rejection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Corporation: Address of Corporation Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Statement Agreement: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Agreement: Alternative Selection: Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Corporation of Authorized Agent: City of Residence: County of Residence: State: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
986 2024-05-13 17:26 Anonymous (not verified) 94.188.207.229 Rail and Road Equipment Co 1797 G50 HWY. St. Charles, IA. 50240 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 Ranae Pontier railandroad@myomnitel.com St Charles Warren IA Abbi Goering Travis Allen Signed (1) The corporation rejects the employers’ liability coverage. Ranae Pontier railandroad@myomnitel.com Vice President St Charles Warren IA Abbi Goering Travis Allen Signed
988 2024-05-14 14:12 Anonymous (not verified) 94.188.205.174 Kobliska Plumbing Inc. 291 Crandall Dr. NE Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-14 Philip P. Kobliska jimfortmann60@gmail.com Cedar Rapids Linn Iowa James J. Fortmann Ruth Beers Signed (1) The corporation rejects the employers’ liability coverage. Philip P. Kobliska jimfortmann60@gmail.com President Cedar Rapids Linn IA James J. Fortmann Ruth Beers Signed
989 2024-05-14 14:14 Anonymous (not verified) 94.188.205.177 Kobliska Plumbing Inc. 291 Crandall Dr. NE Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-14 Philip P. Kobliska jimfortmann60@gmail.com Cedar Rapids Linn Iowa James J. Fortmann Ruth Beers Signed (1) The corporation rejects the employers’ liability coverage. Philip P. Kobliska jimfortmann60@gmail.com President Cedar Rapids Linn IA James J. Fortmann Ruth Beers Signed
173 2021-01-26 19:29 Anonymous (not verified) 173.17.84.174 Robert Schroeder const. inc 10984 150 th. st. davenport ia. 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-26 ROBERT SCHROEDER r.schroeder@aol.com davenport scott ia. Debra Blaser John Ekin Signed (1) The corporation rejects the employers’ liability coverage. ROBERT SCHROEDER r.schroeder@aol.com President davenport scott ia. Debra Blaser John Ekin Signed
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
398 2022-02-01 18:50 Anonymous (not verified) 172.58.83.243 essential renovation LLC 516 e center st, freeport il 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. 2022-02-01 teodoro jimenez essentialrenovations.llc@gmail.com freeport stephenson il adam spear karly spear Signed (1) The corporation rejects the employers’ liability coverage. sandra cuatlatl essentialrenovations.llc@gmail.com owner freeport stephenson il adam spear karly spear Signed
844 2023-12-29 08:28 Anonymous (not verified) 94.188.207.226 Emcubed Enterprises, Inc 979 40th Ave, Bettendorf, IA 52722 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-12-29 Bradley David Morrison brad@riverbendsignworks.com Moline Rock Island IL David Rodriguez Lisbet Lule Signed (1) The corporation rejects the employers’ liability coverage. Bradley David Morrison brad@riverbendsignworks.com Owner Moline Rock Island IL David Rodriguez Lisbet Lule Signed
862 2024-01-22 13:55 Anonymous (not verified) 94.188.207.228 Emcubed Enterprises, Inc 979 40th Ave, Bettendorf, IA 52722 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-22 Bradley D Morrison brad@riverbendsignworks.com Moline Rock Island IL Richard Henning Kyle Sebben Signed (1) The corporation rejects the employers’ liability coverage. Brad Morrison brad@riverbendsignworks.com Owner Moline Rock Island IL Richard Henning Kyle Sebben Signed
965 2024-04-30 10:47 Anonymous (not verified) 94.188.205.177 Billy Dudock 148818 Argo Fay Rd 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. 2024-04-30 Billy Dudock mitzi@bruggemanlumber.com Thompson Carroll IL Roger Gibbs Mitzi Hoeger Signed (1) The corporation rejects the employers’ liability coverage. Billy Dudock mitzi@bruggemanlumber.com Self Thompson Carroll Il Roger Gibbs Mitzi Hoeger Signed
978 2024-05-08 13:47 Anonymous (not verified) 94.188.205.174 Meridian Logistics, LLC 5249 N Park Pl NE, Unit #2060, Cedar Rapids, IA 52402 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-05-07 Abigail Matthews almsolutions2021@gmail.com Chicago Cook IL Gayle Matteson Jane Calvert Signed (2) The corporation declines to reject the employers’ liability coverage. Abigail Matthews almsolutions2021@gmail.com Owner Chicago Cook IL Gayle Matteson Jane Calvert Signed
16 2019-12-12 13:17 Anonymous (not verified) 65.126.161.162 MGF Concrete DBA Michael Frandsen 3306 66th Avenue Moline, IL 61265 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. 2019-12-12 Michael Frandsen None@none.com Moline Rock Island Illinois Sarah Robertson Beth Welzenbach Signed (1) The corporation rejects the employers’ liability coverage. Michael Frandsen None@none.com Owner Moline Rock Ilsand Illinois Sarah Robertson Beth Welzenbach Signed
23 2019-12-31 09:01 Anonymous (not verified) 65.126.161.162 Shawn Watson DBA SW Painting 1205 13th Ave Orion, IL 61273 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. 2019-12-31 Shawn Michael Watson None@none.com Orion Henry Illinois Sarah Robertson Beth Welzenbach Signed (1) The corporation rejects the employers’ liability coverage. Shawn Watson None@none.com Owner Orion Henry Illinois Sarah Robertson Beth Welzenbach Signed
187 2021-02-25 10:44 Anonymous (not verified) 173.27.130.150 Southside Boat Club Post Office Box 674, Keokuk, Iowa 52632 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-01 Michael Oney Mahoney southsideboatclub@gmail.com Keokuk Lee Iowa Roger D. Huston Janis Leann Wallingford Signed (1) The corporation rejects the employers’ liability coverage. Jeri Denise Asbridge Kerryasbridge1@mediacombb.net Treasurer Hamilton Hancock Illinois Roger D. Huston Janis Leann Wallingford Signed
327 2021-09-07 08:58 Anonymous (not verified) 173.28.32.129 Sas Entertainment, Inc. PO Box 47 LeClaire, IA 52753 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. 2021-09-07 Randy Saskowski sales@sasdjs.com Geneseo henry illinois Dan Terry Joe Roberts Signed (1) The corporation rejects the employers’ liability coverage. randy Saskowski sales@sasdjs.com President Geneseo henry illinois Dan Terry Joe Roberts Signed
670 2023-05-18 12:21 Anonymous (not verified) 94.188.205.175 innovations General contractors 1134 20th ave East Moline IL 61244 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. 2022-05-18 Juan Carlos innovationsGENC@gmail.com East Moline Rock Island Illinois Jacinto Perez Lopez Pionaolo Davalos Signed (1) The corporation rejects the employers’ liability coverage. juan Carlos Soto Deanda InnovationsGENC@gmail.com owner East moline Rock Island illinois jacinto Perez Lopez Pianolo Davalos Signed
673 2023-05-23 07:07 Anonymous (not verified) 94.188.207.224 Mulgrew Seamless Gutters 12 REMINGTON PARK CIR east dubuque Illinois 61025 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. 2023-05-22 Edward mulgrew Emulgrew78@gmail.com East Dubuque Jo Davis Illinois Mike Venable Claudia Venable Signed (1) The corporation rejects the employers’ liability coverage. Edward mulgrew Emulgrew78@gmail.com Owner East Dubuque Jo Davis Illinois Edward mulgrew Edward c mulgrew Signed
674 2023-05-23 07:08 Anonymous (not verified) 94.188.207.223 Mulgrew Seamless Gutters 12 REMINGTON PARK CIR east dubuque Illinois 61025 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. 2023-05-22 Edward mulgrew Emulgrew78@gmail.com East Dubuque Jo Davis Illinois Mike Venable Claudia Venable Signed (1) The corporation rejects the employers’ liability coverage. Edward mulgrew Emulgrew78@gmail.com Owner East Dubuque Jo Davis Illinois Edward mulgrew Edward c mulgrew Signed
731 2023-08-04 09:43 Anonymous (not verified) 94.188.207.229 Hopp's Computers & More 855 S. Page St., Nauvoo, IL 62354 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-04 James Hopp tech@hoppcomputers.com Nauvoo Hancock Illinois Carol McGhghy Ana LeVesque Signed (1) The corporation rejects the employers’ liability coverage. James Hopp tech@hoppcomputers.com Owner Nauvoo Hancock Illinois Carol McGhghy Ana LeVesque Signed
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
886 2024-02-06 19:20 Anonymous (not verified) 94.188.207.227 juan carlos ruiz perez 2010 seventh st desmoines, 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. 2024-02-06 juan carlos ruiz perez jruizperez898@gmail.com desmoines polk iowa guadalupe Gonzalez rojo Javier Villeda Hernandez Signed (1) The corporation rejects the employers’ liability coverage. juan c ruiz perez jruizperez898@gmail.com owner desmoines polk in guadalupe gonzalez rojo Javier Villeda Hernandez Signed
17 2019-12-12 13:20 Anonymous (not verified) 65.126.161.162 Robert J Schroeder Const. Inc. 10984 150th St Davenport, IA 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2019-12-12 Robert J Schroeder None@none.com Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed (1) The corporation rejects the employers’ liability coverage. Robert J Schroeder None@none.com President Davenport Scott Iowa Sarah Robertson Beth Welzenbach 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
25 2020-01-02 09:17 Anonymous (not verified) 207.191.194.182 Waukee CabinetWorks LLC 70 SE Laurel St, Waukee IA 50263 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. 2019-12-23 Jason Balm chris.rappe@waukeecabinetworks.com Waukee Dallas Iowa Chris Andrews Dave Creighton Sr Signed (1) The corporation rejects the employers’ liability coverage. Chris Rappe chris.rappe@waukeecabinetworks.com Operations Manager Waukee Dallas Iowa Chris Andrews Dave Creighton SR Signed
26 2020-01-07 11:00 Anonymous (not verified) 208.95.1.97 Rumours Sports Bar & Grill 309 N 12th Ave Place Marshalltown IA 50158 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. 2019-11-07 Jason Priske darla.rowley@insurecentraliowa.com Marshalltown Marshall Iowa Darla Rowley Samantha Garrison Signed (1) The corporation rejects the employers’ liability coverage. Jason Priske darla.rowley@insurecentraliowa.com Owner Marshalltown Marshall Iowa Darla Rowley Samantha Garrison Signed
27 2020-01-07 11:03 Anonymous (not verified) 208.95.1.97 Rumours Sports Bar and Grill 309 N 12th Avenue Place Marshalltown IA 50158 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. 2019-11-07 Janet Priske darla.rowley@insurecentraliowa.com Marshalltown Marshall Iowa Darla Rowley Samantha Garrison Signed (1) The corporation rejects the employers’ liability coverage. Janet Priske darla.rowley@insurecentraliowa.com Owner Marshalltown Marshall Iowa Darla Rowley Samantha Garrison Signed
32 2020-01-14 10:33 Anonymous (not verified) 108.171.132.189 B & C Lawn Care Inc P.O. Box 55, Boone, IA 50036 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. 2020-01-01 Travis Garrett onethird4599@gmail.com Boone Boone Iowa Katie Frame Jessica Carroll Signed (1) The corporation rejects the employers’ liability coverage. Travis Garrett onethird4599@gmail.com Owner Boone Boone IOWA Katie Frame Jessica Carroll Signed
34 2020-01-16 13:10 Anonymous (not verified) 108.171.132.188 B & C Lawn Care Inc P.O. Box 55, Boone, IA 50036 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. 2020-01-01 Caleb Elliott onethird4599@gmail.com Boone Boone Iowa Katie Frame Jessica Carroll Signed (1) The corporation rejects the employers’ liability coverage. Caleb Elliott onethird4599@gmail.com Owner Boone Boone IOWA Katie Frame Jessica Carroll Signed
35 2020-01-31 14:56 Anonymous (not verified) 96.31.22.239 HOGMILE PORK LLC 2032 220TH ST INWOOD, IOWA 51240 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. 2020-01-31 GALEN VANDEVEGTE galenvv@alliancecom.net INWOOD LYON IOWA LISA FABER ERIC TEGROOTENHUIS Signed (1) The corporation rejects the employers’ liability coverage. GALEN VANDEVEGTE galenvv@alliancecom.net SELF INWOOD LYON IOWA LISA FABER ERIC TEGROOTENHUIS Signed
36 2020-01-31 14:59 Anonymous (not verified) 96.31.22.239 HOGMILE PORK LLC 2032 220TH ST INWOOD IOWA 51240 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. 2020-01-31 GLENN VANDEVEGTE glenvv@alliancecom.net INWOOD LYON IOWA LISA FABER ERIC TEGROOTENHUIS Signed (1) The corporation rejects the employers’ liability coverage. GLENN VANDEVEGTE glennvv@alliancecom.net self INWOOD LYON IOWA LISA FABER ERIC TEGROOTENHUIS Signed
38 2020-02-08 13:16 Anonymous (not verified) 208.126.52.97 Savage Industries Inc 2368 110th street Delmar, ia 52037 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. 2020-02-08 Jordan Hicks jjjhicks22@gmail.com Delmar Clinton Iowa Brittany Hicks Alex Laban Signed (1) The corporation rejects the employers’ liability coverage. Jordan Hicks jjjhicks22@gmail.com President Delmar Clinton Iowa Brittany Hicks Alex Laban Signed
39 2020-02-10 16:37 Anonymous (not verified) 67.212.103.193 Voelker Property Management, LLC 1705 Quail Run Lane, Cedar Falls, 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. 2020-02-10 Craig D Voelker cvoelker@cfu.net Cedar Falls Black Hawk Iowa Craig DVoelker Nikki D Voelker Signed (1) The corporation rejects the employers’ liability coverage. Craig D Voelker cvoelker@cfu.net Owner Cedar Falls Black Hawk Iowa Craig D Voelker Nikki D Voelker Signed
41 2020-02-16 19:09 Anonymous (not verified) 207.199.193.217 S J Hernandez, Inc 19738 133rd Street 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. 2020-02-16 Jessica Hernandez jessieatcjs@gmail.com Bloomfield Davis Iowa Salvador Hernandez-Perez Joseph Olinger Signed (1) The corporation rejects the employers’ liability coverage. Jessica Hernandez jessieatcjs@gmail.com Owner Bloomfield Davis Iowa Salvador Hernandez-Perez Joseph Olinger Signed
42 2020-02-16 19:13 Anonymous (not verified) 207.199.193.217 S J Hernandez, Inc 19738 133rd Street 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. 2020-02-16 Salvador Hernandez-Perez jessieatcjs@gmail.com Bloomfield Davis Iowa Jessica Hernandez Joseph Olinger Signed (1) The corporation rejects the employers’ liability coverage. Salvador Hernandez-Perez jessieatcjs@gmail.com Owner Bloomfield Davis Iowa Jessica Hernandez Joseph Olinger Signed
43 2020-02-28 09:50 Anonymous (not verified) 173.24.140.77 W R Main Contractor Inc 1620 NW 78th Street, Clive, IA 50325 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-02-28 Cindy Jo Ohmart co4mainco@aol.com West Des Moines Polk Iowa Jill Ann Reber Alane Marguerite Richardson Signed (1) The corporation rejects the employers’ liability coverage. Mark I Main markmain@icloud.com President Waukee Dallas Iowa Jill Ann Reber Alane Marguerite Richardson Signed
44 2020-03-09 10:51 Anonymous (not verified) 184.63.116.185 STURCO BUILDERS 24472 15TH AVE NEW VIRGINIA IA 50210 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. 2020-03-09 LANE WILLIAM STURTZ Sturcobuilders@live.com New virginia warren Iowa EMILY LAURA STURTZ JODI LEEANN GARNER Signed (1) The corporation rejects the employers’ liability coverage. LANE WILLIAM STURTZ Sturcobuilders@live.com OWNER NEW VIRGINIA WARREN IOWA EMILY LAURA STURTZ JODI LEEANN GARNER Signed
47 2020-03-10 15:16 Anonymous (not verified) 65.126.161.162 Advantage Customer Remodeling LLC 3236 W 17th Street Davenport, IA 52804 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-03-10 Tamethia Mitchell None@none.com Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed (1) The corporation rejects the employers’ liability coverage. Tamethia Mitchell None@none.com Owner Davenport Scott Iowa Sarah Robertson Beth Welzenbach Signed
48 2020-03-18 09:58 Anonymous (not verified) 67.22.192.111 Rozeboom Trucking Inc. PO Box 110 Sioux Center IA 51250 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. 2020-03-18 Kirk Hulstein kirkh@barkcattle.com Sioux Center Sioux Iowa Linda Kieft Tiffany Govig Signed (1) The corporation rejects the employers’ liability coverage. Kirk Hulstein kirkh@barkcattle.com president Sioux Center Sioux Iowa Linda Kieft Tiffany Govig Signed
49 2020-03-18 10:03 Anonymous (not verified) 67.22.192.111 Rozeboom Trucking Inc. PO Box 110 Sioux Center IA 51250 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. 2020-03-18 Kelly Hulstein kellyh@barkcattle.com Sioux Center Sioux Iowa Linda Kieft Tiffany Govig Signed (1) The corporation rejects the employers’ liability coverage. Kirk Hulstein kirkh@barkcattle.com president Sioux Center Sioux Iowa Linda Kieft Tiffany Govig Signed
50 2020-03-18 10:06 Anonymous (not verified) 67.22.192.111 Rozeboom Trucking Inc. PO Box 110 Sioux Center IA 51250 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. 2020-03-18 Kraig Hulstein kraigh@barkcattle.com Sioux Center Sioux Iowa Linda Kieft Tiffany Govig Signed (1) The corporation rejects the employers’ liability coverage. Kirk Hulstein kirkh@barkcattle.com president Sioux Center Sioux Iowa Linda Kieft Tiffany Govig Signed
51 2020-03-30 11:01 Anonymous (not verified) 45.42.5.219 Iowa Roofpros 104 Anderson Street, Maquoketa, IA 52060 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. 2020-03-17 Heather Nienke heather@nienkesolar.com Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Heather Nienke heather@nienkesolar.com Co-owners Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed
52 2020-03-30 11:04 Anonymous (not verified) 45.42.5.219 Iowa Roofpros 104 Anderson Street, Maquoketa, IA 52060 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. 2020-03-17 Jamison Nienke iowaroofguru@gmail.com Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Jamison Nienke iowaroofguru@gmail.com Co-owners Maquoketa Jackson Iowa Derrick Parsons Brenda Lewis Signed
53 2020-03-30 11:09 Anonymous (not verified) 45.42.5.219 Taylor's Tri-State Construction 660 Tanzanite Drive, 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. 2020-03-06 John Taylor taylorsconstruction78@yahoo.com Dubuque Dubuque Iowa Brenda Lewis Jessica Stepp Signed (1) The corporation rejects the employers’ liability coverage. John Taylor taylorsconstruction78@yahoo.com Co-owners Dubuque Dubuque Iowa Brenda Lewis Jessica Stepp Signed
55 2020-04-06 16:25 Anonymous (not verified) 74.221.44.37 Steele Land & Livestock, Inc 1040 190th St, Anita, IA 50020 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. 2020-04-06 Doug Steele dsteele@midlands.net Anita Adair Iowa Sheryl Leonard Cheryl Ellis Signed (1) The corporation rejects the employers’ liability coverage. Doug Steele dsteele@midlands.net President Anita Adair Iowa Sheryl Leonard Cheryl Ellis Signed
56 2020-04-10 11:12 Anonymous (not verified) 136.34.78.83 KALONA SALES BARN, INC. 121 9TH ST; KALONA, IA 52247 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-06 LAVAUGHN MULLET LMULLET@KALONASALESBARN.COM KALONA WASHINGTON IOWA ALANA MULLET ROCHELLE MULLET Signed (1) The corporation rejects the employers’ liability coverage. LAVAUGHN MULLET LMULLET@KALONASALESBARN.COM OWNER KALONA WASHINGTON IOWA ALANA MULLET ROCHELLE MULLET Signed
57 2020-04-10 11:14 Anonymous (not verified) 136.34.78.83 KALONA SALES BARN, INC. 191 9TH STREET; KALONA, IA 52247 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-07 DEVIN MULLET LMULLET@KALONASALESBARN.COM KALONA WASHINGTON IOWA ALANA MULLET ROCHELLE MULLET Signed (1) The corporation rejects the employers’ liability coverage. DEVIN MULLET LMULLET@KALONASALESBARN.COM OWNER KALONA WASHINGTON IOWA ALANA MULLET ROCHELLE MULLET Signed
58 2020-04-14 08:32 Anonymous (not verified) 174.217.17.57 Society of St Vincent de Paul, District Counsel Waterloo Iowa 320 Broadway St PO Box 2727 Waterloo IA 50704 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. 2020-04-14 Rodney Crowe crorod@aol.com Waterloo Blackhawk Iowa George W Karnivk Glynis R Worthington Signed (1) The corporation rejects the employers’ liability coverage. Joseph D Sobczyk joczyk@aol.com Corporate Treasurer Cdear Falls Blackhawk Iowa George W Karnick Glynis R Worthington Signed
59 2020-04-14 12:54 Anonymous (not verified) 65.126.161.162 Elite Carpentry 1515 21st Street Bettendorf, IA 52722 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-04-10 Jeffrey D. Leech elitecarpentryqc@gmail.com Bettendorf Scott Iowa Sarah Robertson Beth Welzenbach Signed (2) The corporation declines to reject the employers’ liability coverage. Jeffrey D. Leech elitecarpentryqc@gmail.com President Bettendorf Scott Iowa Sarah Robertson Beth Welzenbach Signed
60 2020-04-20 13:06 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, PO Box 609, Arnolds Park, IA 51331 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. 2020-04-01 Charley Whittenburg jennifer@walkerinsuranceia.com Spencer Clay Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Charley Whittenburg jennifer@walkerinsuranceia.com Vice President Spencer Clay Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed
61 2020-04-20 13:13 Anonymous (not verified) 173.24.181.211 Historic Arnolds Park Inc 37 Lake Street, P.O. Box 609 Arnolds Park, IA 51331 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. 2020-04-01 Bruce Tamisiea jennifer@walkerinsuranceia.com Wahpeton Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed (1) The corporation rejects the employers’ liability coverage. Bruce Tamisiea jennifer@walkerinsuranceia.com Board Member Wahpeton Dickinson Iowa Joseph Thomas Loring Jennifer Janet Youngwirth Signed