218 |
2021-03-29 08:04 |
Anonymous (not verified) |
173.18.193.51 |
Lee County Fair, Inc |
PO Box 179, Donnellson, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-03-03 |
Matthew Wilson |
judy@fullenkampins.com |
Donnellson |
Lee |
Iowa |
Lindsey Lampe |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Matthew Wilson |
judy@fullenkampins.com |
Board Member |
Donnellson |
Lee |
Iowa |
l0 |
Judy Moeller |
Signed |
937 |
2024-03-30 17:30 |
Anonymous (not verified) |
94.188.205.167 |
AR Drilling LLC |
1821 Roebling Rd, Adel, IA 50003 |
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 |
Luis Serrano |
serranoluis7667@gmail.com |
Adel |
Dallas |
IA |
Kelly green |
Thomas Green |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Luis Serrano |
serranoluis7667@gmail.com |
Owner |
Adel |
Dallas |
IA |
Kelly Green |
Thomas Green |
Signed |
330 |
2021-09-08 10:20 |
Anonymous (not verified) |
206.80.128.71 |
H F Corporation |
105 Oskaloosa St Pella, IA 50219 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-09-08 |
Nayan Patel |
super8pella@gmail.com |
Pella |
Marion |
Iowa |
Mark Chambers |
Jim Wessels |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeremy Rogstad |
jeremy@jeremyrogstad.com |
State Farm Agent |
Charles City |
Floyd |
Iowa |
Mark Chambers |
Jim Wessels |
Signed |
442 |
2022-04-11 13:15 |
Anonymous (not verified) |
75.162.175.12 |
Castro construction LLC |
1712 carpenter av desmoines Iowa 50314 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-04-11 |
Carlos Alberto castro Alcántara |
castrodvxhd@gmail.com |
Estados Unidos |
Iowa |
Desmoines |
Blanca Yadira montes Quiñones |
Maynor Noe padilla bonilla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carlos Alberto castro Alcántara |
castrodvxhd@gmail.com |
Owner |
Estados unidos |
Iowa |
Desmoines |
Blanca Yadira montes Quiñones |
Maynor Noe Padilla Bonilla |
Signed |
554 |
2022-10-03 15:44 |
Anonymous (not verified) |
75.162.176.251 |
SBM Construction Inc |
3023 1st St |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-09-03 |
Mike Guerrero |
service@fritzins.com |
Des Moines |
Polk |
Iowa |
David Fritz |
Matthew Fritz |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Mike Guerrero |
service@fritzins.com |
Owner |
Des Moines |
Polk |
Iowa |
David Fritz |
Matthew Fritz |
Signed |
666 |
2023-05-05 16:20 |
Anonymous (not verified) |
94.188.205.177 |
Furever Friends Rescue of Appanoose, Inc |
PO Box 663, Centerville, Iowa 52544 |
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. |
2023-05-05 |
Michael Miller |
mrmillerfb@gmail.com |
Centerville |
Appanoose |
Iowa |
Kimberly Stonehouse |
Jennifer Appler |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Miller |
mrmillerfb@gmail.com |
Secretary |
Centerville |
Appanoose |
Iowa |
Kimberly Stonehouse |
Jennifer Appler |
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 |
890 |
2024-02-19 12:07 |
Anonymous (not verified) |
94.188.205.174 |
FJ Orisa Construction Inc |
114 Austin Street 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. |
(1) I reject the employers’ liability coverage. |
2024-02-19 |
Jennifer LynnWeirup |
FJOrisaconstruction@yahoo.com |
Cedar Rapids |
Linn |
IA |
Karen Sedlacek |
Billie Jo Moore |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
jennifer lynn weirup |
FJOrisaconstruction@yahoo.com |
self |
Cedar Rapids |
Iowa |
Iowa |
Karen Sedlacek |
Billie Jo Moore |
Signed |
231 |
2021-04-11 12:19 |
Anonymous (not verified) |
174.243.115.140 |
Blaser Plumbing Inc |
28933 Sieverding Ridge Rd Bellevue IA 52031 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-04-11 |
Michael Blaser |
bpi1999@hotmail.com |
Bellevue |
IA |
United States |
Joyce Langmeier |
Sylvester Langmeier |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Blaser |
bpi1999@hotmail.com |
Owner |
Bellevue |
IA |
United States |
Joyce Langmeier |
Sylvester Langmeier |
Signed |
950 |
2024-04-08 07:16 |
Anonymous (not verified) |
94.188.207.223 |
J&J Exteriors |
32670 190th st granger Iowa 50109 |
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. |
2024-04-08 |
Joshua w klein |
jjexteriorsofiowa@gmail.com |
Granger |
Dallas |
Iowa |
Leah klein |
Ethan faughn |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joshua klein |
jjexteriorsofiowa@gmail.com |
Member |
Granger |
Dallas |
Iowa |
Leah klein |
Ethan Faughn |
Signed |
343 |
2021-10-07 15:12 |
Anonymous (not verified) |
73.191.238.89 |
Kleaveland Brothers, Inc. |
c/o 5724 36th Avenue NE, Seattle, WA 98105 |
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. |
2021-10-07 |
Michael I. Kleaveland |
kleaveland@comcast.net |
Muskegon |
Muskegon |
MI |
Amanda A. Finch |
Enrika L.F. McGahan |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael I. Kleaveland |
kleaveland@comcast.net |
Secretary/Treasurer |
Muskegon |
Muskegon |
MI |
Amanda A. Finch |
Enrika L.F. McGahan |
Signed |
455 |
2022-04-27 14:04 |
Anonymous (not verified) |
184.80.177.137 |
Classic Custom Cabinets, Inc |
31931 Bries Drive , 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. |
2022-04-27 |
Mike Then |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
567 |
2022-11-14 18:21 |
Anonymous (not verified) |
166.181.83.71 |
Beasts Bussiness |
1305 N 6th St Apt. 6 Indianola, IA 50125 |
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. |
2022-11-14 |
Jonathan Brice Robinson |
Beastsbeekeeping@gmail.com |
Indianola |
Warren |
Iowa |
Timothy Williams Robinson |
Josiah Grant Robinson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jonathan Brice Robinson |
Beastsbeekeeping@gmail.com |
Owner |
Indianola |
Warren |
Iowa |
Timothy Williams Robinson |
Josiah Grant Robinson |
Signed |
679 |
2023-06-06 10:36 |
Anonymous (not verified) |
94.188.205.174 |
William Terrance Harshbarger Jr. |
27225 115th Avenue, Donahue IA 52746 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-06 |
William Terrance Harshbarger Jr. |
harzyhd1@hotmail.com |
Donahue |
Scott |
Iowa |
Margaret Tucker |
Cheryl Piersall |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William Terrance Harshbarger Jr. |
harzyhd1@hotmail.com |
self |
Donahue |
Scott |
Iowa |
Margaret Tucker |
Cheryl Piersall |
Signed |
791 |
2023-10-17 16:21 |
Anonymous (not verified) |
94.188.207.229 |
HEIMGARTNER INSURANCE INC |
26511 Hedge 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. |
2023-10-17 |
Travis Heimgarter |
travis.insure@gmail.com |
Merrill |
ia |
United States |
Malinda Short |
Scott Delperdang |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis Heimgarter |
travis.insure@gmail.com |
President |
Merrill |
ia |
United States |
Malinda Short |
Scott Delperdang |
Signed |
23 |
2019-12-31 09:01 |
Anonymous (not verified) |
65.126.161.162 |
Shawn Watson DBA SW Painting |
1205 13th Ave Orion, IL 61273 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2019-12-31 |
Shawn Michael Watson |
None@none.com |
Orion |
Henry |
Illinois |
Sarah Robertson |
Beth Welzenbach |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Shawn Watson |
None@none.com |
Owner |
Orion |
Henry |
Illinois |
Sarah Robertson |
Beth Welzenbach |
Signed |
135 |
2020-11-20 11:05 |
Anonymous (not verified) |
208.95.1.97 |
Burds Communities Inc. |
606 S 3rd Street, Bellevue, IA 52031 |
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. |
2020-11-20 |
Todd Burds |
burdshousing@yahoo.com |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Todd Burds |
burdshousing@yahoo.com |
President |
Peosta |
Dubuque |
IA |
Paula Fitzgerald |
Jena Wilwert |
Signed |
247 |
2021-04-27 09:35 |
Anonymous (not verified) |
207.191.206.210 |
United windows and siding |
4080 1st Avenue NE, Cedar Rapids Iowa 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. |
(2) I decline to reject the employer’s liability coverage. |
2021-04-27 |
Adrian Sanchez |
adrian@unitedwindowsandsiding.com |
Aurora |
CO |
United States |
Megan Bierley |
Ginger Berens |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Adrian Sanchez |
adrian@unitedwindowsandsiding.com |
Owner |
Aurora |
Jeffereson |
CO |
Megan Bierley |
Ginger Berens |
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 |
359 |
2021-11-15 09:43 |
Anonymous (not verified) |
165.225.57.41 |
Jerry Steward Trucking Inc |
319 W. 7th Street, Janesville, IA 50647 |
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. |
2021-10-22 |
Jerry Steward Jr. |
cedarfalls.oil@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jerry Steward Sr. |
cedarfalls.oil@gmail.com |
President |
Cedar Falls |
Black Hawk |
Iowa |
Meredith Morrow |
Susan Fiser |
Signed |
471 |
2022-05-13 10:08 |
Anonymous (not verified) |
104.166.245.37 |
Juan Ramiro Rivas Perez |
6211 SW 5th Street. 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. |
2022-05-02 |
Juan Ramiro Rivas Perez |
cecyperezv1982@icloud.com |
Des Moines |
Polk |
Iowa |
Carmen Perez |
Oscar Ramirez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Juan Ramiro Rivas Perez |
cecyperezv1982@icloud.com |
Secretary |
Des Moines |
Polk |
Iowa |
Carmen Perez |
Oscar Ramirez |
Signed |
583 |
2022-12-09 11:29 |
Anonymous (not verified) |
74.84.79.78 |
Captain Kirk Construction |
202 W Guthrie St. Linden, IA 50146 |
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 |
William Kirj |
iicaptainkirk@gmail.com |
Linden |
Dalas |
Iowa |
Michael O'Conner |
Ron Rand |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William Kirk |
iicaptainkirk@gmail.com |
Owner |
Linden |
Dallas |
IA |
Michael O'Conner |
Casey Kirk |
Signed |
695 |
2023-06-20 13:27 |
Anonymous (not verified) |
94.188.207.227 |
Canvas Products Co. |
182 Main Street Dubuque, Iowa 52001 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-06-20 |
Mary A.Salwolke |
maryann@dbqcanvas.com |
Dubuque |
IA |
Iowa |
Ashley A. Trowbridge |
Taylor J. Trowbridge |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Frank J. Salwolke |
frank@dbqcanvas.com |
President |
Dubuque |
Ia |
Iowa |
Ashley A. Trowbridge |
Taylor J. Trowbridge |
Signed |
807 |
2023-11-07 11:25 |
Anonymous (not verified) |
94.188.205.167 |
Keokuk Termite & Pest Control, INC. |
P.O.Box 422 Keokuk, IA 52632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-07 |
Marc Lee Floyd |
keokuktermite@gmail.com |
Keokuk |
Lee |
Iowa |
Kayla Joanne Tonkin |
Esther Mae Floyd |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marc Lee Floyd |
keokuktermite@gmail.com |
Owner |
Keokuk |
Lee |
Iowa |
Kayla Joanne Tonkin |
Esther Mae Floyd |
Signed |
39 |
2020-02-10 16:37 |
Anonymous (not verified) |
67.212.103.193 |
Voelker Property Management, LLC |
1705 Quail Run Lane, Cedar Falls, Iowa |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-10 |
Craig D Voelker |
cvoelker@cfu.net |
Cedar Falls |
Black Hawk |
Iowa |
Craig DVoelker |
Nikki D Voelker |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Craig D Voelker |
cvoelker@cfu.net |
Owner |
Cedar Falls |
Black Hawk |
Iowa |
Craig D Voelker |
Nikki D Voelker |
Signed |
151 |
2021-01-01 11:26 |
Anonymous (not verified) |
75.162.130.160 |
The Product Boss LLC |
20 Mountain Way, West Orange, NJ 07052 |
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. |
2021-01-01 |
Minna Khounlo-Sithep |
minna@theproductboss.com |
Ankeny |
IA |
IA |
Nalinh Sithep |
Suzzan Khounlo |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Minna Khounlo-Sithep |
minnaks@gmail.com |
Co-Owner |
Ankeny |
IA |
IA |
Nalinh Sithep |
Suzzan Khounlo |
Signed |
263 |
2021-05-06 15:18 |
Anonymous (not verified) |
174.243.113.232 |
Agronomic Solutions |
908 E Dubuque St Quasqueton IA 52326 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-05-06 |
Brandy Hodges |
mapping@agsolutionsinc.net |
Coon Rapids |
IA |
United States |
Jacki Sloss |
Don Sloss |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Friday Insurance |
doug.miller@fridayinsurance.net |
agent |
Osceola |
Clarke |
IA |
Jacki Sloss |
Don Sloss |
Signed |
982 |
2024-05-10 19:06 |
Anonymous (not verified) |
94.188.207.228 |
Revella Salon and Spa |
509 Second 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. |
2024-05-10 |
Bailey Roeder |
roeder428@gmail.com |
Ida Grove |
Ida |
Iowa |
Dalton Hemer |
Fina Roeder |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bailey Roeder |
roeder428@gmail.com |
Myself |
Ida Grove |
Ida |
Iowa |
Dalton Hemer |
Fina Roeder |
Signed |
375 |
2021-12-23 12:23 |
Anonymous (not verified) |
66.230.245.47 |
W. R. Elliot & Associates, Ltd. |
3306 Brook Hollow Dr, Asbury, 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. |
2021-12-23 |
William R. Elliot |
bill@wreassoc.com |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L. Spalla |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
William R. Elliot |
bill@wreassoc.com |
President |
Asbury |
Dubuque |
IA |
Thomas J Spalla |
Nancy L Spalla |
Signed |
487 |
2022-06-02 08:36 |
Anonymous (not verified) |
173.18.193.51 |
Wever Fire Association |
1692 354th Avenue, Wever, Iowa 52658 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-25 |
Jacob Denning |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jacob Denning |
judy@fullenkampins.com |
Board Member |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
599 |
2023-02-13 12:14 |
Anonymous (not verified) |
94.188.207.227 |
Christian Gilbert |
3174 HWY F48 W. Newton, IA 50208 |
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. |
2023-02-13 |
Christian Gilbert |
christian.gilbert14@gmail.com |
Newton |
Jasper |
Iowa |
Marcus Thompson |
Crystal Ward |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christian Gilbert |
christian.gilbert14@gmail.com |
self |
Newton |
Jasper |
Iowa |
Marcus Thompson |
Crystal Ward |
Signed |
711 |
2023-07-24 12:04 |
Anonymous (not verified) |
94.188.205.176 |
HAIGH & ESPE LIMITED |
1198 GRAND AVE, MARION, IA 52302 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-07-24 |
LYNN M. HAIGH |
ADAMSTILEANDSTONE@GMAIL.COM |
Cedar Rapids |
Linn |
Iowa |
DAVID REIBSAMEN |
STACEY ROGERS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
LYNN M. HAIGH |
ADAMSTILEANDSTONE@GMAIL.COM |
CORP. SECRETARY |
CEDAR RAPIDS |
LINN |
IOWA |
DAVID REIBSAMEN |
STACEY ROGERS |
Signed |
823 |
2023-11-20 14:04 |
Anonymous (not verified) |
94.188.205.169 |
CDNE, Inc. |
311 E. Alta Vistta 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. |
2023-11-20 |
Craig Allen Payne |
Craig.Payne@indianhills.edu |
Ottumwa |
Wapello |
Iowa |
Erin Elizabeth Payne |
Nathan Thomas Payne |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Desirae Lynn Payne |
desip845@gmail.com |
Spouse |
Ottumwa |
Wapello |
Iowa |
Erin Elizabeth Payne |
Nathan Thomas Payne |
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 |
167 |
2021-01-26 11:56 |
Anonymous (not verified) |
74.84.91.178 |
Shea Real Estate LLC |
135 Devon Drive, Dubuque, IA 52001 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-12-17 |
Lucas Kahl |
shearealestatellc@gmail.com |
Dubuque |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lucas Kahl |
shearealestatellc@gmail.com |
President |
Dubuque |
Dubuque |
Iowa |
Gabe Drewelow |
Brenda Lewis |
Signed |
279 |
2021-06-23 10:41 |
Anonymous (not verified) |
184.80.177.137 |
AA Breeders |
P.O. Box 470 - Epworth, IA 52045 |
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. |
2021-06-22 |
Justin Curtis |
jheims@english-insurance.com |
Epworth |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
AA Breeders - Justin Curtis |
jheims@english-insurance.com |
self |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
998 |
2024-05-23 15:12 |
Anonymous (not verified) |
94.188.207.224 |
JTG Consulting LLC |
3945 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. |
2024-05-23 |
Jake Thomas Guckenberger |
jtgconsultingllc1@gmail.com |
Des Moines |
IA |
United States |
Jake Thomas Guckenberger |
Alex Dougherty |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jake Thomas Guckenberger |
jtgconsultingllc1@gmail.com |
Owner |
Des Moines |
IA |
United States |
Jake T Guckenberger |
Alex Dougherty |
Signed |
391 |
2022-01-26 16:08 |
Anonymous (not verified) |
207.199.212.86 |
Geerts Plumbing and Heating Inc. |
913 N Linn Ave, New Hampton, IA 50659 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-07 |
Adam S Geerts |
lacy@cioia.com |
New Hampton |
Chickasaw |
Iowa |
Lacy Carolan |
Maddi Moorman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam S Geerts |
lacy@cioia.com |
Owner |
New Hampton |
Chickasaw |
Iowa |
Lacy Carolan |
Maddi Moorman |
Signed |
503 |
2022-06-30 17:15 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise |
101 Ashworth 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. |
2022-06-30 |
Nexhat Krasniqi |
nexhat_80@hotmail.com |
WEST DES MOINES |
polk |
Iowa |
Sandro Tadic |
Andy Swanson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandro Tadic |
sanienterprise14@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
Sandro Tadic |
Andy Swanson |
Signed |
615 |
2023-02-28 08:15 |
Anonymous (not verified) |
94.188.207.224 |
River City Transport |
201 Lezlie Dr |
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. |
2023-02-28 |
Christopher Ryan Brewer |
chris@rivercitylogistics.net |
Peosta |
Dubuque County |
Iowa |
Brian Brewer |
Nicholas Lester |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Chris Brewer |
chris@rivercitylogistics.net |
Owner |
Peosta |
Iowa |
United States |
Brian Brewer |
Nicholas Lester |
Signed |
727 |
2023-08-02 18:25 |
Anonymous (not verified) |
94.188.205.176 |
Furever Friends Rescue of Appanoose, Inc |
19507 Hwy 2, Centerville, Iowa 52544 |
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. |
2023-08-02 |
Krystal Fowler |
krystalfowler@gmail.com |
Cincinnati |
Appanoose |
Iowa |
Jennifer Appler |
Kimberly Stonehouse |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Krystal Fowler |
krystalfowler@gmail.com |
Treasurer |
Cincinnati |
Appanoose |
Iowa |
Jennifer Appler |
Kim Stonehouse |
Signed |
839 |
2023-12-18 16:12 |
Anonymous (not verified) |
94.188.207.227 |
515 Painting llc |
po box 157 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-12-18 |
Marvin S Parker JR |
stvpkr@gmail.com |
berwick |
polk |
iowa |
Christopher Eldridge |
Dillon Parker |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Marvin parker |
stvpkr@gmail.com |
owner |
berwick |
Polk |
Iowa |
Christopher Eldridge |
Dillon Parker |
Signed |
71 |
2020-04-27 16:23 |
Anonymous (not verified) |
140.82.166.162 |
Loss Control Specialist Inc |
1409 Jackson Woods Ct NW Cedar Rapids, IA 52409 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-02-28 |
James Riggert |
jim@losscontrolspecialist.com |
Cedar Rapids |
Linn |
Iowa |
Megan Thomas |
Jessica Droppert |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
James Riggert |
jim@losscontrolspecialist.com |
President |
Cedar Rapids |
Linn |
Iowa |
Megan Thomas |
Jessica Droppert |
Signed |
183 |
2021-02-18 08:54 |
Anonymous (not verified) |
173.18.193.51 |
Freeman Family Farms Inc |
3125 Glasgow Rd Fairfield Iowa 52556 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-08 |
David Freeman |
jill@fullenkampins.com |
Fairfield |
Jefferson |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Freeman |
jill@fullenkampins.com |
President |
Fairfield |
Jefferson |
Iowa |
Jill A Garmoe |
Judy K Moeller |
Signed |
902 |
2024-02-26 11:37 |
Anonymous (not verified) |
94.188.207.228 |
roorda dairy llc |
5128 460th st |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-02-22 |
scott roorda |
scottyroorda@hotmail.com |
granville |
obrien county |
iowa |
lance roorda |
larry roorda |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
kyle blankers |
kyle@veinsurance.com |
member |
5128 460th st |
obrien county |
iowa |
lance roorda |
larry roorda |
Signed |
295 |
2021-07-27 15:13 |
Anonymous (not verified) |
75.162.64.21 |
Homars Concrete Inc. |
2439 se 19th st Des Moines IA 50320 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-07-16 |
Omar Sacramento |
yasiel558@gmail.com |
Des Moines |
Polk |
Iowa |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Omar Sacramento |
yasiel558@gmail.com |
owner |
Des Moines |
polk |
iowa |
liliana sanchez |
yolanda mendoza |
Signed |
407 |
2022-02-16 15:44 |
Anonymous (not verified) |
173.18.126.91 |
Huff Construction LLC |
1309 Business 30 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. |
(1) I reject the employers’ liability coverage. |
2022-02-16 |
Jason Huff |
jason@huff-construction.com |
Mount Vernon |
Linn |
Iowa |
Katie Huff |
Rick Deneve |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jason Huff |
jason@huff-construction.com |
Owner |
Mount Vernon |
Linn |
Iowa |
Katie Huff |
Rick Deneve |
Signed |
519 |
2022-07-22 13:55 |
Anonymous (not verified) |
162.253.44.28 |
Seeger Truck Trailer Repair, Inc. |
1125 66th AVE 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. |
2022-08-01 |
Eldora Seegers |
royalwsilverII@gmail.com |
Cedar Rapids |
Linn |
Iowa |
John Seegers |
Julie Jones |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Eldora Seergers |
royalwsilverII@gmail.com |
Officer |
Cedar Rapids |
Linn |
Iowa |
John Seegers |
Julie Jones |
Signed |
631 |
2023-03-22 13:33 |
Anonymous (not verified) |
94.188.205.167 |
Prime Rock Finishing LLC |
440 NW 50th PL Des Moines Iowa 50313 |
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 |
Ludwing Paredes |
primerockfinishing@gmail.com |
Des Moines |
Polk |
Iowa |
x |
x |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Ludwing Paredes |
primerockfinishing@gmail.com |
President |
Des Moines |
Polk |
Iowa |
x |
x |
Signed |
743 |
2023-08-15 15:03 |
Anonymous (not verified) |
94.188.205.177 |
R & T Trucking LLC |
1374 Creamery Road, Afton Iowa 50830 |
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. |
2023-08-15 |
Robert Dike |
robandteenadike@outlook.com |
Afton |
Union |
Iowa |
Kristina Dike |
Robert Dike |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert Dike |
robandteenadike@outlook.com |
Owner |
Afton |
Union |
Iowa |
Kristina Dike |
Robert Dike |
Signed |