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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:
734 2023-08-09 10:33 Anonymous (not verified) 94.188.207.227 Atcher Service LLC 145 Fremont Street, Hartford, IA 50118 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-08 Mandalena K Love dlovem2002@gmail.com Hartford Warren Iowa Dan Love Michael Love Signed (1) The corporation rejects the employers’ liability coverage. Daniel J Love atcherservicetowing@gmail.com owner Hartford Warren Iowa Dan Love Michael Love Signed
802 2023-10-25 08:34 Anonymous (not verified) 94.188.205.174 CEM Businesses LLC 607 evergreen cir nw Bondurant, IA 50035 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-10-25 Dustin Rudolph dmrudo@gmail.com Des Moines Polk Iowa Cameron VanBuren Raelynn Aicher Signed (1) The corporation rejects the employers’ liability coverage. Dane McDonald dane.mcdonald@stellar-solar.net Self Bondurant Polk Iowa Cameron VanBuren Raelynn Aicher 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
138 2020-11-24 14:11 Anonymous (not verified) 173.215.17.41 Dohrmann Enterprises, Inc 2478 260th Ave. DeWitt, Iowa 52742 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. 2020-11-24 Joel Dohrmann dohrmannpnh@gmail.com DE WITT Clinton IA Susanne Owen Daron Oberbroecking Signed (1) The corporation rejects the employers’ liability coverage. Susanne Owen sowen@ohnward.com none Camanche Clinton Iowa Joel Dohrmann Daron Oberbroecking Signed
145 2020-12-18 07:54 Anonymous (not verified) 173.215.16.15 Dohrmann Enterprises Inc 2652 350th Ave DeWitt, IA 52742 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-18 Tom Dohrmann dohrmannpnh@gmail.com DeWitt Clinton Iowa Susanne Owen Daron Oberbroeckling Signed (1) The corporation rejects the employers’ liability coverage. Tom Dohrmann dohrmannpnh@gmail.com Owner DeWitt Clinton Iowa Susanne Owen Daron Oberbroeckling Signed
872 2024-01-26 10:28 Anonymous (not verified) 94.188.205.177 Sole proprietor- Dennis R. Oliver dba Olivers Oasis Communications 150 Spring Valley Ct. Springtown, TX 76082 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-26 Dennis Reeves Oliver doliversoasis@aol.com Springtown Parker Texas Helen Frances Steil John Kevin Steil Signed (1) The corporation rejects the employers’ liability coverage. Dennis Reeves Oliver doliversoasis@aol.com Self Springtown Parker TX Helen Frances Steil John Kevin Steil Signed
161 2021-01-14 19:19 Anonymous (not verified) 108.174.118.195 Four Seasons HVAC LLC 3165 Four Seasons Drive, Stevensville, MT 59870 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-01-14 Douglas Michael Ostrenga doug@fourseasonshvac.com Stevensville Ravalli MT Zachery Donald Wiediger Thomas Maximillian Liedtka Signed (1) The corporation rejects the employers’ liability coverage. Julie Ruthanne Ostrenga julie@fourseasonshvac.com Member Manager Stevensville Ravalli MT Zachery Donald Wiediger Thomas Maximillian Liedtka Signed
966 2024-04-30 14:39 Anonymous (not verified) 94.188.207.230 Bowman Dozing & Excavating LLC 218 134th ave 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. 2024-04-30 Bradley D Bowman dozermann9@hotmail.com Maquoketa Jackson Iowa Jennifer Machande Mitchell Schaller Signed (1) The corporation rejects the employers’ liability coverage. Bradley D Bowmann dozermann9@hotmail.com owner/president maquoketa Jackson iowa Jennifer Machande Mitch Schaller Signed
80 2020-05-11 12:29 Anonymous (not verified) 173.191.207.202 J&D Furniture-Land Corp 144 1st Ave East - Dyersville, IA 52040 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-05-07 Scott Hittenmiller dparsons@english-insurance.com Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Joyce Heims jheims@english-insurance.com agent-English Insurance Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
515 2022-07-19 10:06 Anonymous (not verified) 184.80.177.137 Mom Clean, LLC 4 East 3rd Street - Earlville, IA 52041 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. 2022-07-18 Morgan Lahr dparsons@english-insurance.com Dyersville Delaware IA Derrick Parsons Joyce Heims Signed (1) The corporation rejects the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com self Dyersville Dubuque IA Derrick Parsons Joyce Heims Signed
542 2022-09-26 19:26 Anonymous (not verified) 45.78.142.139 Doyle Vondrak Trucking 315 Vermont Avenue, Kingsley, Iowa 51028 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. 2022-09-26 Doyle P Vondrak dpvondrak@wiatel.net Kingsley Plymouth Iowa Jayne R Vondrak Jesse M Vondrak Signed (1) The corporation rejects the employers’ liability coverage. Doyle P Vondrak dpvondrak@wiatel.net self-employed; single employee Kingsley Plymouth Iowa Jayne R Vondrak Jesse M Vondrak Signed
636 2023-03-23 15:49 Anonymous (not verified) 94.188.207.229 Pacifica Health Services, LLC 4911 SW 19th St, Des Moines, IA 50315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-03-23 Robert Conner dr.conner@metrogeriatrics.com Norwalk Warren Iowa Jackie Hastings Amber Perdue Signed (1) The corporation rejects the employers’ liability coverage. Jennifer Conner jconner@viahealthservices.com President Des Moines Polk IA Jackie Hastings Amber Perdue Signed
495 2022-06-08 13:07 Anonymous (not verified) 173.31.148.43 OKOBOJI PERFORMING ARTS 97 WOODLIN DR MILFORD, IA 51351 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. 2022-06-08 DREW DUNCAN DREW@OKOBOJIPERFORMINGARTS.COM LINCOLN LANCASTER NE JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The corporation rejects the employers’ liability coverage. DREW DUNCAN DREW@OKOBOJIPERFORMINGARTS.COM SELF LINCOLN LANCASTER NE JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
941 2024-04-03 10:26 Anonymous (not verified) 94.188.207.223 Andrew Renna 407 19th st spirit lake Iowa 51369 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 Andrew John Renna drewrenna86@gmail.com Spirit lake Dickinson Iowa Brianna Lene Nicholas Omang Signed (1) The corporation rejects the employers’ liability coverage. Andrew Renna drewrenna86@gmail.com Owner Spirit lake Dickinson Iowa Brianna Lene Nicholas Omang 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
168 2021-01-26 12:06 Anonymous (not verified) 74.84.91.178 RAM Services 13276 Harvest Mood Ridge, Sherrill, IA 52073 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-11 Dusty Herbst dustyherbst@hotmail.com Sherrill Dubuque Iowa Derrick Parsons Brenda Lewis Signed (1) The corporation rejects the employers’ liability coverage. Dusty Herbst dustyherbst@hotmail.com President Sherrill Dubuque Iowa Derrick Parsons Brenda Lewis Signed
632 2023-03-22 13:44 Anonymous (not verified) 94.188.205.177 Midwest Home Solutions Inc 150 Light Rd., Lisbon, IA 52253 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. 2023-03-22 Ean Michael Caskey ean_caskey@hotmail.com Lisbon Linn IA Trista Leigh Schaffner Christopher Ray Schaffner Signed (1) The corporation rejects the employers’ liability coverage. Ean Michael Caskey ean_caskey@hotmail.com President Lisbon Linn Iowa Trista Leigh Schaffner Christopher Ray Schaffner Signed
639 2023-03-27 12:24 Anonymous (not verified) 94.188.207.230 Midwest Home Solutions Inc 150 Light Road, Lisbon, IA 52253 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. 2023-03-16 Ean Caskey ean_caskey@hotmail.com Lisbon Linn IA Corey Scott Daniel Munro Signed (1) The corporation rejects the employers’ liability coverage. Daniel Munro danielmunro@gmail.com Agent Oceanside CA United States Corey Scott Daniel Munro Signed
478 2022-05-24 13:16 Anonymous (not verified) 63.146.149.12 EBN CONSTRUCTION LLC 314 NE 5TH ST, ANKENY IA 50021 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-05-24 Juan J Perez Munoz ebnconstruction@icloud.com Des Moines Polk Iowa Jaime Leiva Kevin Pham Signed (1) The corporation rejects the employers’ liability coverage. Juan J Perez Munoz ebnconstruction@icloud.com Owner Des MOines Polk Iowa Jaime Leiva Kevin Pham Signed
132 2020-11-03 13:22 Anonymous (not verified) 173.22.125.16 BeraTek Industries 407 9th Ave SE, Cedar Rapids, IA 52401 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. 2020-11-03 Ethan Davidson edavidson@beratek-industries.com Cedar Rapids Linn Iowa Raymond Gerald Beranek Ethan Paul Davidson Signed (1) The corporation rejects the employers’ liability coverage. Ethan Paul Davidson edavidson@beratek-industries.com President Cedar Rapids Linn Iowa Raymond Gerald Beranek Ethan Paul Davidson Signed
118 2020-09-15 14:32 Anonymous (not verified) 174.243.115.133 Jurisdiction Approved Plumbing Corporation P.O. Box 343 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. 2020-09-15 Christian m Lavia eeejumble@gmail.com Urbandale Polk Iowa Tina m Heuckendorf Roslyn Heuckendorf Signed (1) The corporation rejects the employers’ liability coverage. Christian m Lavia eeejumble@gmail.com Director Urbandale Polk IOWA Tina m Heuckendorf Roslyn Heukendorf Signed
226 2021-04-01 11:52 Anonymous (not verified) 97.125.87.4 JK Holdings 1300 NW 100TH ST. Suite 3000 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. 2020-04-01 Joey Boyens ekindesmoines@gmail.com Clive Polk Iowa Jenae Halstead Cam Naylor Signed (1) The corporation rejects the employers’ liability coverage. Jenae Halstead ekindesmoines@gmail.com Manager Clive Polk Iowa Joey Boyens Cam Naylor 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
148 2020-12-30 08:22 Anonymous (not verified) 166.181.83.201 Elite Carpentry P.O. Box 1162 Bettendorf Iowa 52722 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2020-12-30 Jeffrey D Leech Elitecarpentryqc@gmail.com Bettendorf Scott Iowa Jeremy Havens Michael Rodriguez Signed (1) The corporation rejects the employers’ liability coverage. Jeffrey D Leech Elitecarpentryqc@gmail.com Owner Bettendorf Scott Iowa Jeremy Havens Michael Rodriguez Signed
778 2023-10-02 10:15 Anonymous (not verified) 94.188.205.166 Medinas Tile 2365 267th Street Oskaloosa, Iowa 52577 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. 2023-10-02 Leon Medinas elleonmedina@hotmail.com Oskaloosa Mahaska Iowa Rocio Medinas Manuel Lopez Signed (1) The corporation rejects the employers’ liability coverage. Leon Medina elleonmedina@hotmail.com Owner Oskaloosa Mahaska Iowa Rocio Medina Manuel Lopez Signed
643 2023-03-30 09:58 Anonymous (not verified) 94.188.205.175 Adamantine Spine Moving 2726 Independence Rd., Iowa City, IA 52240 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. 2023-03-30 Emily Wallace emily.wallace@spinemoving.com Des Moines Polk Iowa John Wallace Ashley Koch Signed (1) The corporation rejects the employers’ liability coverage. Ashley Koch ashley.koch@spinemoving.com Human Resources Manager West Des Moines Polk Iowa John Wallace Taylor Roth Signed
970 2024-05-02 16:15 Anonymous (not verified) 94.188.205.167 Adamantine Spine Moving 2726 Independence Rd., Iowa City, IA 52240 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. 2024-05-02 Emily Wallace emily.wallace@spinemoving.com Des Moines Polk Iowa Margaret Walter Dan Walter Signed (1) The corporation rejects the employers’ liability coverage. William Hoke bill.hoke@spinemoving.com Owner Iowa City Johnson Iowa Sarah Mannix Erika Banks Signed
851 2024-01-14 15:40 Anonymous (not verified) 94.188.205.169 B St. Construction + Design, Inc. 16 Southwest 42nd Street I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2024-01-13 Emily Renze-Crouch emily@bstdesigner.com Des Moines Iowa United States Jodi Essex Linda K Renze Signed (1) The corporation rejects the employers’ liability coverage. Emily Renze-Crouch emily@bstdesigner.com Vice President / CFO Des Moines IA United States Jodi Essex Linda K Renze Signed
936 2024-03-30 16:41 Anonymous (not verified) 94.188.205.176 Rhubarb Botanicals LLC 650 Martelle Rd, Springville IA 52336 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. 2024-03-30 Emma Barber emma@rhubarbbotanicals.com Springville Linn Iowa Lena Wilhelm Harvey Wilhelm Signed (1) The corporation rejects the employers’ liability coverage. Emma Barber emma@rhubarbbotanicals.com Co-Owner Springville Linn Iowa Lena Wilhelm Harvey Wilhelm 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
433 2022-03-27 15:30 Anonymous (not verified) 208.126.206.146 J B Engraving 206 4th street East Newhall , Iowa 52315 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. 2022-03-27 John Lauterwasser engravingjb@gmail.com Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed (1) The corporation rejects the employers’ liability coverage. LC Anderson lbandins@southslope.net N/A Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed
434 2022-03-27 15:30 Anonymous (not verified) 208.126.206.146 J B Engraving 206 4th street East Newhall , Iowa 52315 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. 2022-03-27 John Lauterwasser engravingjb@gmail.com Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed (1) The corporation rejects the employers’ liability coverage. LC Anderson lbandins@southslope.net N/A Newhall Benton Iowa Lisa Jane Meeks Brandon Lauterwasser Signed
581 2022-12-09 11:23 Anonymous (not verified) 74.84.79.78 Avila Gutters 5901 SW 5th St. Des Moines, IA 50315 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-01-01 Enrique Avila Ceballos enrique86avila@gmail.com Des Moines Polk Iowa Michael O'Conner Ron Rand Signed (1) The corporation rejects the employers’ liability coverage. Enrique Avila Ceballos enrique86avila@gmail.com Owner Des Moines Polk Iowa Michael O'Conner Ron Rand Signed
440 2022-03-29 20:05 Anonymous (not verified) 174.215.228.20 Navarro construction 2825 SE 14th St lot #6 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. 2022-03-29 Enrique Navarro enriquenavarro887@gmail.com Des Moines Polk IA Alondra Navarro René Navarro Signed (1) The corporation rejects the employers’ liability coverage. Enrique Navarro enriquenavarro884@gmail.com Owner Des moines Polk IA Alondra Navarro René Navarro Signed
876 2024-01-30 17:55 Anonymous (not verified) 94.188.207.230 Erik Mortens 9823 nw 46th ct polk city iowa 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. 2024-01-30 Erik mortens Erik.mortens@gmail.com Polk city Polk Iowa Andrea Davis Kali Davis Signed (1) The corporation rejects the employers’ liability coverage. Erik mortens Erik.mortens@gmail.com Self Polk city Polk Iowa Kali Davis Andrea Davis Signed
345 2021-10-11 15:36 Anonymous (not verified) 173.188.10.36 Outdoor Pros LLC 4525 HWY 22 SE 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. 2021-10-11 Erik Scott Alberhasky erikalberhas@gmail.com LONE TREE IA United States Melanie Hockenson Robin Morrison Signed (1) The corporation rejects the employers’ liability coverage. Erik Scott Alberhasky erikalberhas@gmail.com Owner LONE TREE IA United States Melanie Hockenson Robin Morrison Signed
971 2024-05-03 07:33 Anonymous (not verified) 94.188.205.176 Outdoor Pros LLC 6535 WAPSI AVE SE Lone Tree IA 52755 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. 2024-05-02 Erik Alberhasky erikalberhas@gmail.com LONE TREE IA United States Melanie Hockenson Robin Morrison Signed (1) The corporation rejects the employers’ liability coverage. Erik Alberhasky erikalberhas@gmail.com Owner LONE TREE IA United States Melanie Hockenson Robin Morrison Signed
972 2024-05-03 07:35 Anonymous (not verified) 94.188.205.175 Outdoor Pros LLC 6535 WAPSI AVE SE Lone Tree IA 52755 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. 2024-05-02 Erik Alberhasky erikalberhas@gmail.com LONE TREE IA United States Melanie Hockenson Robin Morrison Signed (1) The corporation rejects the employers’ liability coverage. Erik Alberhasky erikalberhas@gmail.com Owner LONE TREE IA United States Melanie Hockenson Robin Morrison 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
186 2021-02-24 14:35 Anonymous (not verified) 216.51.194.37 Estherville Aviation, Inc. 1672 425th Ave, Estherville, IA 51334 I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2021-02-24 Paul Abrams Slaughter estavtn@yourstarnet.net Estherville Emmet Iowa Jordan Lampman Dwayne Hoss Signed (1) The corporation rejects the employers’ liability coverage. Paul Abrams Slaughter estavtn@yourstarnet.net President Estherville Emmet Iowa Jordan Lampman Dwayne Hoss Signed
748 2023-08-20 14:18 Anonymous (not verified) 94.188.205.177 NexLevelMoving 1186 capital dr sw I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (2) I decline to reject the employer’s liability coverage. 2023-08-16 Ethan Daniel Sailer ethan.sailer@hscsi.net Cedar Rapids Linn County Iowa Denis Sailer Penny Sailer Signed (2) The corporation declines to reject the employers’ liability coverage. Tarin Erenberger tarin.nexlevelmoving@gmail.com Employee Cedar Rapids Linn County Iowa Taj Barrett Taj Barrett Signed
753 2023-08-21 14:21 Anonymous (not verified) 94.188.205.174 NexLevelMoving 1186 Capital Dr Sw, Cedar Rapids I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-08-23 Ethan Daniel Sailer ethan.sailer@hscsi.net Cedar Rapids Linn County Iowa Penny Sailer Denis Sailer Signed (1) The corporation rejects the employers’ liability coverage. Ethan Daniel Sailer ethan.sailer@hscsi.net Self Cedar Rapids Linn County Iowa Penny Sailer Denis Sailer Signed
561 2022-11-03 11:24 Anonymous (not verified) 96.31.21.117 Northwest 9 Inc. 1512 Elmwood Ave. I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2022-11-03 Ethan Meyer ethanmeyer83@gmail.com ROCK RAPIDS Iowa United States Brad Meyer Trinda Meyer Signed (1) The corporation rejects the employers’ liability coverage. Brad Meyer nw9farm@gmail.com owner Rock Rapids IA United States Trinda Meyer Brad Meyer Signed
300 2021-08-03 12:43 Anonymous (not verified) 97.125.35.240 Every Solutions Drywall INC 713 SE 7th St Des Moines, Iowa 50309 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. 2021-08-03 Luis Hernandez everysolutiondrywainc@yahoo.com Des Moines Polk Iowa Kelly Denger Debra Stratton Signed (1) The corporation rejects the employers’ liability coverage. Luis Hernandez everysoloutiondrywainc@yahoo.com Owner Des Moines Polk Ia Kelly Denger Debra Stratton Signed
429 2022-03-24 13:37 Anonymous (not verified) 174.255.1.155 Franky's Construction 1419 Acacia 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. 2022-03-24 Frank Ackley fackley1981@gmail.com Cedar Rapids Linn IA Rick Deneve Kailee Carstensen Signed (1) The corporation rejects the employers’ liability coverage. Franky Ackley fackley1981@gmail.com Owner Cesar Rapids Linn IA Rick DeNeve Kailee Carstensen Signed
430 2022-03-24 14:47 Anonymous (not verified) 173.30.76.116 Franky's Construction 1419 Acacia 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. 2022-03-24 Franky Ackley fackley1981@gmail.com Cedar Rapids Linn IA Rick DeNeve Kailee Carstensen Signed (1) The corporation rejects the employers’ liability coverage. Franky Ackley fackley1981@gmail.com Owner Cedar Rapids Linn IA Rick DeNeve Kailee Carstensen Signed
20 2019-12-30 09:39 Anonymous (not verified) 207.191.194.182 LA Trends Addict Inc 1200 N CENTER POINT 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. 2019-10-07 Laura Frey fcrentals1@gmail.com HIAWATHA Linn IA Traci Lyons Allie DeVore Signed (1) The corporation rejects the employers’ liability coverage. Laura Frey fcrentals1@gmail.com Owner HIAWATHA Linn IA Traci Lyons Allie DeVore Signed
848 2024-01-05 13:05 Anonymous (not verified) 94.188.205.177 NeX Level Moving, LLC 5634 Deerwood St. 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. 2024-01-05 William J Feldmann feldmannwng@msn.com Anamosa Jones Iowa Bridget Camp Signed (1) The corporation rejects the employers’ liability coverage. William J Feldmann feldmannwng@msn.com Self Anamosa Jones Iowa Bridget Camp Signed
773 2023-09-20 13:48 Anonymous (not verified) 94.188.207.225 RHYO SIDING AND RESTORATION 1475 Wilson Avenue, Cedar Rapids I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. (1) I reject the employers’ liability coverage. 2023-09-09 FERDIN CASTELLANOS MERINO ferdincastellanos7@gmail.com Cedar Rapids Linn County IOWA FERDIN CASTELLANOS MERINO GLORIA RODRIGUEZ Signed (1) The corporation rejects the employers’ liability coverage. N/A customerservice@biberk.com N/A N/A N/A N/A N/A N/A Signed