78 |
2020-05-05 16:49 |
Anonymous (not verified) |
173.21.16.121 |
Kevan Oliver Trim Carpentry, Inc. |
2900 Scott Park Road, Eldridge, IA 52748 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2020-05-05 |
Scarlett Oliver |
scarlettioliver@gmail.com |
Eldridge |
Scott |
Iowa |
Franco Muñoz |
Rolando Muñoz |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Kevan Oliver |
kkoliverinc@gmail.com |
President |
Eldridge |
Scott |
Iowa |
Franco Muñoz |
Rolando Muñoz |
Signed |
79 |
2020-05-06 08:14 |
Anonymous (not verified) |
97.125.243.140 |
pro plumbing and heating llc |
903 nw 37th ct ankeny iowa 50023 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-05-06 |
lee d kearney |
ankenypro@gmail.com |
ankeny |
polk |
iowa |
sheila m kearney |
keegan l kearney |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
lee d kearney |
ankenypro@gmail.com |
owner |
ankeny |
IA |
United States |
sheila m kearney |
keegan l kearney |
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 |
81 |
2020-05-11 16:10 |
Anonymous (not verified) |
97.125.253.184 |
Rundle Creations L.L.C. |
5816 Urbandale Avenue, Des Moines, IA 50322 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-05-11 |
Mark Lavern Rundle II |
rundlecreations@gmail.com |
Des Moines |
Polk |
Iowa |
Luis Alex Jimenez |
Jennifer Lea Griffith |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erika Anne Rundle |
rundlecreations@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Luis Alex Jimenez |
Jennifer Lea Griffith |
Signed |
82 |
2020-05-18 15:16 |
Anonymous (not verified) |
184.80.177.137 |
Farmers Best Popcorn, LLC |
110 1st Street North, - Worthington, IA 52078 |
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. |
2020-05-18 |
Jon Ramaekers |
jheims@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 |
self |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
83 |
2020-05-20 12:34 |
Anonymous (not verified) |
108.171.131.188 |
North Iowa Custom Seamless Guttering, Inc |
PO Box 512, 1300 2nd Ave S, Clear Lake, Iowa 50428 |
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. |
2020-05-20 |
Keith E Main |
keithmaincsg@hotmail.com |
Clear Lake |
Cerro Gordo |
Iowa |
Lloyd L Heinselman |
Diane K Harrington |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Keith E Main |
keithmaincsg@hotmail.com |
President |
Clear Lake |
Cerro Gordo |
Iowa |
Lloyd L Heinselman |
Diane K Harrington |
Signed |
84 |
2020-06-01 16:31 |
Anonymous (not verified) |
173.29.126.110 |
TruthPoint Media LLC |
1945 Andrews Drive, Pleasant Hill, IA 50327 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-06-01 |
Robert Lee Moore |
robb@truthpointmedia.com |
Pleasant Hill |
Polk |
Iowa |
Self, Sole Proprietor and LLC Member, TruthPoint Media LLC |
Self, Sole Proprietor and LLC Member, TruthPoint Media LLC |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert L Moore |
robb@truthpointmedia.com |
Self |
Pleasant Hill |
Polk |
Iowa |
Self, Sole Proprietor and LLC Member, TruthPoint Media LLC |
Self, Sole Proprietor and LLC Member, TruthPoint Media LLC |
Signed |
85 |
2020-06-03 17:53 |
Anonymous (not verified) |
75.162.69.231 |
Blackford Foundations Inc |
501 SW Franklin Dr, Ankeny, IA 50023 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-05-01 |
Brenda Marie Blackford |
brendab@blackfordfoundations.com |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brenda Marie Blackford |
brendab@blackfordfoundations.com |
President |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |
86 |
2020-06-03 17:56 |
Anonymous (not verified) |
75.162.69.231 |
Blackford Foundations Inc |
501 SW Franklin Dr, Ankeny, IA 50023 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-05-01 |
Denny Lee Blackford |
blackfordfoundations@gmail.com |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Denny Lee Blackford |
blackfordfoundations@gmail.com |
Secretary |
Ankeny |
Polk |
Iowa |
Saree Luce |
Ricky Eatwell |
Signed |
87 |
2020-06-09 14:49 |
Anonymous (not verified) |
185.169.109.170 |
Sweeney Builders Inc |
511 8th Ave NW |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-06-09 |
Michael Lee Sweeney |
mike@sweeneybuilders.com |
Waukon |
Allamakee |
Iowa |
Shawna Sweeney |
Jean Gavin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Shawna Sweeney |
shawna@sweeneybuilders.com |
Vice President |
Waukon |
Allamakee |
IA |
Mike Sweeney |
Jean Gavin |
Signed |
88 |
2020-06-10 11:36 |
Anonymous (not verified) |
173.28.7.32 |
DMG INSTALLATIONS INC |
5534 NE 17TH ST #4 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-06-10 |
DAVID PAUL DUNLAP |
HAYDAVE@AOL.COM |
DES MOINES |
POLK |
IOWA |
JASON DAVID MUSSO |
CLIFFORD LEE BAKER |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CLIFF BAKER |
CLBAKER@MEDIACOMBB.NET |
PRESIDENT |
ALTOONA |
POLK |
IOWA |
JASON DAVID MUSSO |
DAVID PAUL DUNLAP |
Signed |
89 |
2020-06-10 11:42 |
Anonymous (not verified) |
173.28.7.32 |
DMG INSTALLATIONS INC |
5534 NE 17TH ST #4 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-06-10 |
JASON DAVID MUSSO |
JMUSSO74@GMAIL.COM |
BONDURANT |
POLK |
IOWA |
DAVID PAUL DUNLAP |
CLIFFORD LEE BAKER |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CLIFFORD LEE BAKER |
CLBAKER@MEDIACOMBB.NET |
PRESIDENT |
ALTOONA |
POLK |
IOWA |
JASON DAVID MUSSO |
DAVID PAUL DUNLAP |
Signed |
90 |
2020-06-10 11:46 |
Anonymous (not verified) |
173.28.7.32 |
DMG INSTALLATIONS INC |
5534 NE 17TH ST #4 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-06-10 |
CLIFFORD LEE BAKER |
CLBAKER@MEDIACOMBB.NET |
ALTOONA |
POLK |
IOWA |
DAVID PAUL DUNLAP |
JASON DAVID MUSSO |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CLIFFORD LEE BAKER |
CLBAKER@MEDIACOMBB.NET |
PRESIDENT |
ALTOONA |
POLK |
IOWA |
JASON DAVID MUSSO |
DAVID PAUL DUNLAP |
Signed |
91 |
2020-06-17 17:47 |
Anonymous (not verified) |
166.182.83.28 |
BJJ Painting Inc |
6940 Rolling Ridge CT 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. |
2020-06-17 |
Bradley Johnson |
brad.johnson@fivestarpainting.com |
Cedar Rapids |
Linn |
Iowa |
Mike McClure |
Tony Gaiffe |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bradley Johnson |
brad.johnson@fivestarpainting.com |
President |
Cedar Rapids |
Linn |
Iowa |
Mike McClure |
Tony Gaiffe |
Signed |
96 |
2020-07-03 16:51 |
Anonymous (not verified) |
208.90.8.234 |
Humboldt Co. Ag Society |
311 6th Ave. N Humboldt IA. |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-03 |
Jeffrey D. Halverson |
roadgear54@yahoo.com |
Hardy |
Humboldt |
Iowa |
Marva Anderson |
Paul Davis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffrey Halverson |
roadgear54@yahoo.com |
Vice President |
Hardy |
Humboldt |
Iowa |
Marva Anderson |
Paul Davis |
Signed |
97 |
2020-07-09 10:07 |
Anonymous (not verified) |
173.215.13.54 |
LOS DOS MEXICAN RESTAURANT DBA CASA DE ORO |
1211 2ND ST, PERRY IOWA 50220 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-05-01 |
MARIO LEPE |
DAVID.FINNESETH@FBFS.COM |
PERRY |
DALLAS |
IOWA |
ROBERTA L GILSON |
SANDRA S WHEELER |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
MARIO LEPE |
DAVID.FINNESETH@FBFS.COM |
VICE PRESIDENT |
PERRY |
DALLAS |
IOWA |
ROBERTA L GILSON |
SANDRA S WHEELER |
Signed |
101 |
2020-07-16 13:07 |
Anonymous (not verified) |
173.28.28.57 |
Weikert Properties, LLC |
34520 175th Street, Cedar Falls IA 5061 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-06-23 |
Caleb Weikert |
cmins_re@mchsi.com |
Cedar Falls |
Grundy |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Caleb Weikert |
cmins_re@mchsi.com |
Self |
Cedar Falls |
Grundy |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
103 |
2020-07-23 09:23 |
Anonymous (not verified) |
184.80.177.137 |
Jacob Reiff |
15738 N Cascade Rd - Peosta, IA 52068 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(2) I decline to reject the employer’s liability coverage. |
2020-07-23 |
Jacob Reiff |
jheims@engish-insurance.com |
Peosta, |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
owner |
Peosta |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
104 |
2020-07-24 10:07 |
Anonymous (not verified) |
173.24.248.4 |
Dirty 30 Trucking & Excavating |
3018 Lawnview Drive |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-24 |
Kirkland Davidson |
dirty30iowa@gmail.com |
Mt. Ayr |
Ringgold |
Iowa |
Alexandra Peace |
Rahim Martin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kirkland Davidson |
dirty30iowa@gmail.com |
President |
Des Moines |
Polk |
Iowa |
Alexandra Peace |
Rahim Martin |
Signed |
106 |
2020-07-27 12:12 |
Anonymous (not verified) |
206.125.132.254 |
Pacos Roofing Inc |
837 Lynkaylee Dr Waterloo, IA 50701 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-27 |
Blanca Garcia |
Pacosroofing@outlook.com |
Waterloo |
Black Hawk |
Iowa |
Kaitlin Schepers |
Sarah Whalen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Blanca Garcia |
Pacosroofing@outlook.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Kaitlin Schepers |
Sarah Whalen |
Signed |
107 |
2020-08-04 13:42 |
Anonymous (not verified) |
97.64.131.90 |
BNR Construction INC |
210 4th St Orient, IA 50858 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-08-04 |
Bennie Shinn |
bnrconstllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
108 |
2020-08-19 09:39 |
Anonymous (not verified) |
184.80.177.137 |
Michelle's Vocational Placement LLC |
2642 Farragut Pl., 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. |
2020-08-18 |
Tara Rommel |
jheims@engish-insurance.com |
Davenport |
Scott |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
109 |
2020-08-24 14:41 |
Anonymous (not verified) |
74.84.91.178 |
Rotten Love LLC |
1101 Valentine Drive, Dubuque, IA 52003 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-08-14 |
Carolyn Schmid |
rottenlovellc@gmail.com |
Dubuque |
Dubuque |
Iowa |
Brenda Lewis |
Sue Miller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carolyn Schmid |
rottenlovellc@gmail.com |
partner |
Dubuque |
Dubuque |
IA |
Brenda Lewis |
Sue Miller |
Signed |
110 |
2020-08-25 14:31 |
Anonymous (not verified) |
199.241.229.222 |
Ney Trucking Inc |
5070 Wolff Rd Dubuque, IA 52002 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-08-25 |
Marvin L Ney |
marvin@paramountems.com |
Peosta |
Dubuque |
Iowa |
Karen Ludovissy |
Brenda Weatherwax |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Maria A Ney |
maria@paramountems.com |
Secretary |
Peosta |
Dubuque |
IA |
Karen Ludovissy |
Brenda Weatherwax |
Signed |
111 |
2020-08-25 14:37 |
Anonymous (not verified) |
204.155.61.217 |
BNR Construction INC |
210 4th St Orient,Ia 50858 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-15 |
Bennie Shinn |
bnrconstructllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstructllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
112 |
2020-08-26 10:18 |
Anonymous (not verified) |
97.64.131.90 |
BNR Construction INC |
210 4th St Orient, IA 50858 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-07-15 |
Bennie Shinn |
bnrconstllc@gmail.com |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bennie Shinn |
bnrconstllc@gmail.com |
President |
Orient |
Adair |
Iowa |
Chris Lane |
Thomas Hartsock |
Signed |
113 |
2020-09-03 14:22 |
Anonymous (not verified) |
72.255.74.171 |
James Raymond and Associates Inc |
240 S 1st St, Carlisle, IA 50047 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-03 |
Jim Downs |
jdowns@arrowisg.com |
Carlisle |
Warren |
Iowa |
TJ Cataldo |
Patti Isley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jim Downs |
jdowns@arrowisg.com |
Owner |
Carlisle |
Warren |
Iowa |
TJ Cataldo |
Patti Isley |
Signed |
114 |
2020-09-04 13:11 |
Anonymous (not verified) |
107.182.207.0 |
KEITH N SLYTER |
PO 2632 |
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. |
2020-09-04 |
KEITH N SLYTER |
KNSCONST@GMAIL.COM |
DAVENPORT |
25|IA |
iowa |
KEITH N SLYTER |
KEITH N SLYTER |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
KEITH N SLYTER |
KNSCONST@GMAIL.COM |
owner |
DAVENPORT |
25|IA |
iowa |
KEITH N SLYTER |
KEITH N SLYTER |
Signed |
116 |
2020-09-11 11:42 |
Anonymous (not verified) |
69.57.22.68 |
Brush and Weed Control Specialists, Inc. |
1108 230th Street - Algona, IA 50511 |
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. |
2020-09-11 |
Ruth Jean Lindgren |
bwcontrol@netamumail.com |
Algona |
Kossuth |
Iowa |
James Black |
Katie Melvin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Donald H Reffer |
bwcontrol@netamumail.com |
President and General Manager |
Algona |
Kossuth |
Iowa |
James Black |
Katie Melvin |
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 |
119 |
2020-09-28 10:43 |
Anonymous (not verified) |
174.213.149.6 |
Ddp construction |
1923 63rd st, des moines ,ia 50322 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-09-28 |
Dustin a perry |
perrythedustin@gmail.com |
Urbandale |
Polk |
Iowa |
Lucas jackson |
Cody roth |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Smith Kenyon insurance |
smithkenyon@yahoo.com |
Agent |
Urbandale |
Polk |
Ia |
Lucas jackson |
Cody roth |
Signed |
120 |
2020-10-01 09:34 |
Anonymous (not verified) |
50.82.176.77 |
Kinion Towing Inc. |
100 Industrial Park Drive, Clarence, IA 52216 |
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. |
2020-09-30 |
Dale Kinion |
kinionas@yahoo.com |
Monmouth |
Jones |
Iowa |
Michael Blake |
Jeffrey Case |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dale Kinion |
kinionas@yahoo.com |
President |
Monmouth |
Jones |
Iowa |
Michael Blake |
Jeffrey Case |
Signed |
121 |
2020-10-01 09:40 |
Anonymous (not verified) |
50.82.176.77 |
Kinion Towing Inc. |
100 Industrial Park Drive, Clarence, IA 52216 |
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. |
2020-09-30 |
Adam Kinion |
kinionas@yahoo.com |
Tipton |
Cedar |
Iowa |
Michael Blake |
Jeffrey Case |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Kinion |
kinionas@yahoo.com |
Vice President |
Tipton |
Cedar |
Iowa |
Michael Blake |
Jeffrey Case |
Signed |
123 |
2020-10-20 17:35 |
Anonymous (not verified) |
66.172.250.9 |
Ladwig Constrution |
509 Moorehead St. Ida Grove, IA 51445 |
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. |
2020-10-20 |
Ross Ladwig |
rossladwig@gmail.com |
Ida Grove |
Ida |
Iowa |
Christine Ladwig |
Kya Ladwig |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Ross Ladwig |
rossladwig@gmail.com |
Owner |
Ida Grove |
Ida |
Iowa |
Christine Ladwig |
Kya Ladwig |
Signed |
124 |
2020-10-21 14:07 |
Anonymous (not verified) |
173.23.249.165 |
Madison County Auction Company LLC |
1204 West Summit Winterset, IA 50273 |
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. |
2020-10-09 |
Tim Gomez |
tjagomez@gmail.com |
Winterset |
Madison |
Iowa |
Sheena Earles |
Russell Boggs |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Russell Boggs |
Russell.Boggs@fbfs.com |
None |
St Charles |
madison |
iowa |
Sheena Earles |
Russell Boggs |
Signed |
126 |
2020-10-28 14:31 |
Anonymous (not verified) |
104.207.25.44 |
Little Bison Daycare Center |
404 2nd St. NW Buffalo Center, IA 50424 |
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. |
2020-10-28 |
Cody Tyler Wirtjes |
cody@afschem.com |
Buffalo Center |
Winnebago |
Iowa |
Michael James Perkins |
Garrett Alan Asmus |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cody Tyler Wirtjes |
cody@afschem.com |
Board President |
Buffalo Center |
Winnebago |
Iowa |
Michael James Perkins |
Garrett Alan Asmus |
Signed |
127 |
2020-10-28 14:42 |
Anonymous (not verified) |
104.207.31.201 |
Little Bison Childcar Center, Inc. |
404 2nd St NW |
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. |
2020-10-28 |
Travis Brass |
travis.brass@rakestatesavingsbank.com |
Lakota |
Kossuth |
Iowa |
Tami Jacobson |
Carol Winter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis Brass |
travis.brass@rakestatesavingsbank.com |
Treasurer |
Lakota |
Kossuth |
Iowa |
Tami Jacobson |
Carol Winter |
Signed |
129 |
2020-10-30 11:23 |
Anonymous (not verified) |
184.80.177.137 |
Haberdash Outfitters, Inc. |
109 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. |
2020-10-27 |
Jennifer Recker |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
130 |
2020-11-02 12:40 |
Anonymous (not verified) |
67.55.220.86 |
Little Bison Childcare Center |
404 2nd St NW, Buffalo Center, IA 50424 |
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. |
2020-11-02 |
Joseph Robert Angstman |
angstman.joe@gmail.com |
Buffalo Center |
Winnebago |
Iowa |
Emily Jean Thomsen Angstman |
Pamela Kay Angstman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Robert Angstman |
angstman.joe@gmail.com |
Secretary |
Buffalo Center |
Winnebago |
Iowa |
Emily Jean Thomsen Angstman |
Pamela Kay Angstman |
Signed |
131 |
2020-11-03 10:26 |
Anonymous (not verified) |
207.32.1.185 |
Little Bison Childcare Center |
404 2nd ST NW Buffalo Center, IA. 50424 |
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 |
Megan C Holland |
megzholland@live.com |
Buffalo Center |
Winnebago |
Iowa |
Nicholas D Holland |
Emily J Angstman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Megan C Holland |
megzholland@live.com |
Vice President |
Buffalo Center |
Winnebago |
Iowa |
Nicholas D Holland |
Emily J Angstman |
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 |
134 |
2020-11-16 16:36 |
Anonymous (not verified) |
192.33.191.131 |
Nekola Outdoors Services, Inc |
722 Penrose St, Grinnell IA 50112 |
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. |
2020-11-16 |
Matthew Lee Nekola |
NEKOLAOUTDOORSERVICES@GMAIL.COM |
Grinnell |
Poweshiek |
Iowa |
Josh Lacaeyse |
Frank Heinen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Matthew Lee Nekola |
nekolaoutdoorservices@gmail.com |
President |
Grinnell |
Poweshiek |
Iowa |
Josh Lacaeyse |
Frank Heinen |
Signed |
137 |
2020-11-23 10:11 |
Anonymous (not verified) |
207.32.14.70 |
Community Ambulance Service, Inc. |
15 N 1st St., 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. |
2020-11-18 |
Christopher Fuhrman |
christopher.furhrman@edwardjones.com |
Spirit Lake |
Dickinson |
Iowa |
Sara M Fisher |
Abbie J Fuhrman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher Fuhrman |
christopher.fuhrman@edwardjones.com |
President |
Spirit Lake |
Dickinson |
Iowa |
Sara M Fisher |
Abbie J Fuhrman |
Signed |
139 |
2020-11-24 15:45 |
Anonymous (not verified) |
174.219.2.33 |
Dan Petersen Construction LLC |
1725 South 14th St, Polk City, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-11-24 |
Daniel Petersen |
danpetersenconstruction@gmail.com |
Polk City |
Polk |
Iowa |
Erik Gramenz |
Jim McMurray |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Petersen |
danpetersenconstruction@gmail.com |
Owner |
Polk City |
Polk |
Iowa |
Erik Gramenz |
Jim McMurray |
Signed |
141 |
2020-12-02 09:34 |
Anonymous (not verified) |
208.90.15.53 |
Humboldt Community Daycare, Inc. DBA Kiddie Cats Childcare and Learning Center |
P.O. Box 93 Dakota City, Ia 50529 |
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. |
2020-12-02 |
Travis Goedken |
travisg@cityofhumboldt.org |
Humboldt |
Humboldt |
Iowa |
Ross Sleiter |
Lance Dewinter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis Goedken |
travisg@cityofhumboldt.org |
President |
Humboldt |
Humboldt |
Iowa |
Ross Sleiter |
Lance Dewinter |
Signed |
142 |
2020-12-02 09:39 |
Anonymous (not verified) |
208.90.15.53 |
Humboldt Community Daycare, Inc. DBA Kiddie Cats Childcare and Learning Center |
P.O. Box 93 Dakota City, Ia 50529 |
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. |
2020-12-02 |
Angelique Berry |
dcity@goldfieldaccess.net |
Algona |
Kossuth |
Iowa |
Ross Sleiter |
Scott Curran |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Angelique Berry |
dcity@goldfieldaccess.net |
Secretary/Treasurer |
Algona |
Kossuth |
Iowa |
Ross Sleiter |
Scott Curran |
Signed |
143 |
2020-12-02 09:43 |
Anonymous (not verified) |
208.90.15.53 |
Humboldt Community Daycare, Inc. DBA Kiddie Cats Childcare and Learning Center |
P.O. Box 93 Dakota City, Ia 50529 |
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. |
2020-12-02 |
Rob Dickey |
robd@fsbwc.com |
Gilmore City |
Humboldt |
Iowa |
Ross Sleiter |
Scott Curran |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rob Dickey |
robd@fwbwc.com |
Vice President |
Gilmore City |
Humboldt |
Iowa |
Ross Sleiter |
Scott Curran |
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 |
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 |
152 |
2021-01-04 12:08 |
Anonymous (not verified) |
104.129.206.120 |
Schleswig Transfer Inc |
216 Valley View Dr, Schleswig, IA 51461 |
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. |
2020-11-30 |
Wade Miller |
t.uhl3@joemorten.com |
Schleswig |
Crawford |
Iowa |
Tamara Uhl |
Amy Meseck |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Wade Miller |
t.uhl3@joemorten.com |
President |
Schleswig |
Crawford |
IA |
Tamara Uhl |
Amy Meseck |
Signed |