742 |
2023-08-15 12:06 |
Anonymous (not verified) |
94.188.205.175 |
The Ritz Restaurant, LLC |
232 1st Ave E - 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. |
2023-08-11 |
Dan Engstrom |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Derrick Parsons |
jheims@english-insurance.com |
self |
Dyersville |
IA |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
754 |
2023-08-21 17:14 |
Anonymous (not verified) |
94.188.205.177 |
Burgess Investments DBA Heartland Pest Control Inc |
PO Box 8043 Cedar Rapids, IA 52408 |
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. |
2023-08-21 |
CURT BURGESS |
curtburgess73@gmail.com |
CEDAR RAPIDS |
IA |
United States |
Doug Wilson |
Michael McMeins |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CURT BURGESS |
curtburgess73@gmail.com |
Self |
CEDAR RAPIDS |
IA |
United States |
Doug Wilson |
Michael McMeins |
Signed |
786 |
2023-10-16 07:27 |
Anonymous (not verified) |
94.188.207.230 |
Aurora Aesthetics and Functional Medicine LLC |
713 1st 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. |
2023-10-04 |
Meagan Mclaughlin |
meagan.vitae@gmail.com |
Mount Vernon |
IA |
United States |
Michael Friess |
Stephanie Friess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Michael Friess |
Aurorafunctionalmed@gmail.com |
business manager |
Mt Vernon |
IA |
United States |
Stephanie Friess |
Meagan Friess |
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 |
815 |
2023-11-14 13:42 |
Anonymous (not verified) |
94.188.207.224 |
SunsetSue, LLC |
240 Solomia Court, 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. |
(1) I reject the employers’ liability coverage. |
2023-11-14 |
Lori Sue Stewart |
lori@hrbcplus.com |
Peosta |
IA |
United States |
Mark R Stewart |
Danielle M Leibfried |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lori S Stewart |
lori@hrbcplus.com |
Self |
Peosta |
IA |
United States |
Mark R Stewart |
Danielle M. Leibfried |
Signed |
824 |
2023-11-21 13:22 |
Anonymous (not verified) |
94.188.207.227 |
OhZone. LLC |
852 Washington Street Burlington, IA 52601 |
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. |
2023-11-19 |
Jeffery W Ishmael |
jeffishmael@gmail.com |
Des Moines |
IA |
United States |
Juan DeLlanos |
Gregory Gunter |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeffery W Ishmael |
jeffishmael@gmail.com |
Co-Owner |
Des Moines |
IA |
United States |
Juan DeLlanos |
Gregory Gunter |
Signed |
829 |
2023-11-27 08:59 |
Anonymous (not verified) |
94.188.207.224 |
Adam Ruess Masonry |
206.w Elm st |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-11-27 |
Adam Ruess |
ruess33@gmail.com |
Lone Tree |
IA |
United States |
Adam Ruess |
Adam Ruess |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Adam Ruess |
ruess33@gmail.com |
Owner |
Lone Tree |
IA |
United States |
Adam Ruess |
Adam Ruess |
Signed |
851 |
2024-01-14 15:40 |
Anonymous (not verified) |
94.188.205.169 |
B St. Construction + Design, Inc. |
16 Southwest 42nd Street |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-13 |
Emily Renze-Crouch |
emily@bstdesigner.com |
Des Moines |
Iowa |
United States |
Jodi Essex |
Linda K Renze |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Emily Renze-Crouch |
emily@bstdesigner.com |
Vice President / CFO |
Des Moines |
IA |
United States |
Jodi Essex |
Linda K Renze |
Signed |
852 |
2024-01-14 15:48 |
Anonymous (not verified) |
94.188.205.166 |
B St. Construction + Design, Inc. |
16 Southwest 42nd Street |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-14 |
Travis D Crouch |
trvscrouch@gmail.com |
Des Moines |
Iowa |
United States |
Jodi Essex |
Linda K Renze |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Travis D Crouch |
trvscrouch@gmail.com |
President |
Des Moines |
IA |
United States |
Jodi Essex |
Linda K Renze |
Signed |
863 |
2024-01-23 13:59 |
Anonymous (not verified) |
94.188.205.176 |
United Marble & Tile, Inc. |
915 8th Street, #201, Boone, IA. 50036 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-24 |
Albert James Gotta |
jim@umtile.com |
Slater |
Boone |
IA |
Antonina M Gotta |
MARY KATE RUSSELL |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Albert James Gotta |
jim@umtile.com |
President Sole Share Holder |
Boone |
IA |
IA |
Antonina M Gotta |
Antonina M Gotta |
Signed |
874 |
2024-01-29 14:30 |
Anonymous (not verified) |
94.188.205.174 |
Proefco LLC |
502 s Cadwell 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. |
2024-01-30 |
Kendy Melendrez |
kendydej@gmail.com |
Eagle Grove |
IA |
IA |
Kendy Melendrez |
Jaime Hernandez |
Signed |
(2) The corporation declines to reject the employers’ liability coverage. |
Kendy Melendrez |
kendydej@gmail.com |
owner |
Eagle Grove |
IA |
IA |
Kendy Melendrez |
Jaime Hernandez |
Signed |
898 |
2024-02-24 21:06 |
Anonymous (not verified) |
94.188.207.226 |
Under Pressure Pressure on |
1008 Doubletree Ct NE |
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. |
2024-02-24 |
Kevin M Feeney |
kevin.feeney45@gmail.com |
Cedar Rapids |
IA |
United States |
Taryn Erbes |
Susan Erbes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kevin M Feeney |
kevin.feeney45@gmail.com |
Owner |
Cedar Rapids |
IA |
United States |
Taryn Erbes |
Susan Erbes |
Signed |
920 |
2024-03-18 15:42 |
Anonymous (not verified) |
94.188.207.223 |
Great Tree LLC |
2701 e douglas 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. |
2024-03-18 |
Robert buell |
Greattree55@gmail.com |
Des Moines |
IA |
United States |
ryan homan |
Jamarlo fields |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert buell |
Greattree55@gmail.com |
company owner |
Des Moines |
IA |
United States |
ryan homan |
jamarlo fields |
Signed |
921 |
2024-03-18 15:45 |
Anonymous (not verified) |
94.188.207.226 |
Great Tree LLC |
2701 e douglas 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. |
2024-03-18 |
Timothy Buell |
treeshark52@gmail.com |
Des Moines |
IA |
United States |
ryan homan |
Jamarlo fields |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Robert buell |
Greattree55@gmail.com |
company owner |
Des Moines |
IA |
United States |
ryan homan |
jamarlo fields |
Signed |
926 |
2024-03-20 15:25 |
Anonymous (not verified) |
94.188.207.230 |
CML Constuction LLC |
2116 Park Ave Muscatine, Iowa 52761 |
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. |
2024-03-20 |
CHRIS LINNENKAMP |
cmlconstructionllc@gmail.com |
Muscatine |
IA |
IA |
Gabriel Diaz |
Byron Lopez |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CHRIS LINNENKAMP |
cmlconstructionllc@gmail.com |
Owner |
Muscatine |
IA |
IA |
Gabriel Diaz |
Byron Lopez |
Signed |
927 |
2024-03-20 23:27 |
Anonymous (not verified) |
94.188.205.177 |
RRB, LLC |
4444 1st Ave NE Ste 510 Cedar Rapids, IA 52402 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-03-20 |
Kelli Holton |
kelli@rebelroseboutique.co |
Coralville |
IA |
United States |
Dave Booth |
Ann Holton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kelli Holton |
kelli@rebelroseboutique.co |
Owner |
Coralville |
IA |
United States |
Dave Booth |
Ann Holton |
Signed |
942 |
2024-04-03 12:06 |
Anonymous (not verified) |
94.188.205.174 |
Invisible Fence of NCI, Inc |
408 5th St, Ste 100 |
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. |
2024-04-04 |
Lisa Busch Timm |
centraliowa@invisiblefence.com |
Madrid |
Iowa |
United States |
Paul Timm |
Kari Rigby |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Busch Timm |
centraliowa@invisiblefence.com |
Self |
Madrid |
IA |
United States |
Paul Timm |
Kari Rigby |
Signed |
943 |
2024-04-03 12:07 |
Anonymous (not verified) |
94.188.205.166 |
Invisible Fence of NCI, Inc |
408 5th St, Ste 100 |
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. |
2024-03-04 |
Paul Andy Timm |
ifbcentraliowa@yahoo.com |
Madrid |
IA |
Iowa |
Lisa Timm |
Kari Rigby |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Busch Timm |
centraliowa@invisiblefence.com |
Spouse |
Madrid |
IA |
United States |
Lisa Timm |
Kari Rigby |
Signed |
945 |
2024-04-03 20:00 |
Anonymous (not verified) |
94.188.207.229 |
Timberview Construction |
803 TIMBERVIEW 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. |
(1) I reject the employers’ liability coverage. |
2024-04-03 |
Parker Evans |
Pcevans28@gmail.com |
ADEL |
IA |
United States |
jason Evans |
Tricia Evans |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Timberview Construction |
Pcevans28@gmail.com |
Myself |
ADEL |
IA |
United States |
Jason Evans |
Tricia Evans |
Signed |
951 |
2024-04-08 10:59 |
Anonymous (not verified) |
94.188.205.167 |
McBee Trucking, LLC |
5029 HARDING 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. |
2024-04-08 |
Gary McBee |
accounting@mcbeetrucking.com |
Prole |
Warren |
Iowa |
Gary McBee |
Elizabeth Reid |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
GARY MCBEE |
gary@mcbeetrucking.com |
Owner |
PROLE |
IA |
United States |
GARY MCBEE |
Elizabeth Reid |
Signed |
961 |
2024-04-25 13:08 |
Anonymous (not verified) |
94.188.207.227 |
PROEFCO LLC |
502 South Cadwell Avenue |
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. |
2024-04-25 |
Kendy Melendrez Figueroa |
Kendydej@gmail.com |
Eagle Grove |
IA |
United States |
Kendy M Figueroa |
Kendy M Figueroa |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kendy M Figueroa |
Kendydej@gmail.com |
Owner |
Eagle Grove |
IA |
United States |
Kendy M Figueroa |
Kendy M Figueroa |
Signed |
971 |
2024-05-03 07:33 |
Anonymous (not verified) |
94.188.205.176 |
Outdoor Pros LLC |
6535 WAPSI AVE SE Lone Tree IA 52755 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-02 |
Erik Alberhasky |
erikalberhas@gmail.com |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik Alberhasky |
erikalberhas@gmail.com |
Owner |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
972 |
2024-05-03 07:35 |
Anonymous (not verified) |
94.188.205.175 |
Outdoor Pros LLC |
6535 WAPSI AVE SE Lone Tree IA 52755 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-02 |
Erik Alberhasky |
erikalberhas@gmail.com |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Erik Alberhasky |
erikalberhas@gmail.com |
Owner |
LONE TREE |
IA |
United States |
Melanie Hockenson |
Robin Morrison |
Signed |
974 |
2024-05-06 08:02 |
Anonymous (not verified) |
94.188.205.176 |
Milton Recycling & Roll Off Service LLC |
1266 218 PL, Boone, IA 50036 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-05-06 |
Glenn Kreuder |
kreuderfarms@yahoo.com |
Boone |
IA |
United States |
Amanda Krull |
Adam Krull |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Glenn Kreuder |
kreuderfarms@yahoo.com |
Member |
Boone |
IA |
United States |
Amanda Krull |
Adam Krull |
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 |
227 |
2021-04-02 09:58 |
Anonymous (not verified) |
207.177.7.191 |
GOETTSCH DISPATCH INC |
200 MAIN ST GALVA, IA 51020 |
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. |
2021-03-15 |
ANDREW GOETTSCH |
andygoettsch@gmail.com |
Galva |
Ida |
Iowa |
Kristy Dewey |
Terri Ullrich |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrew Goettsch |
andygoettsch@gmail.com |
President |
Galva |
Ida |
Iowa |
Kristy Dewey |
Terri Ullrich |
Signed |
845 |
2024-01-02 09:03 |
Anonymous (not verified) |
94.188.205.169 |
American Tree Service LLC |
416 S Kiel Street, Holstein, IA 51025 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2024-01-02 |
Austin Thevenot |
americantreeservice03@gmail.com |
Holstein |
Ida |
Iowa |
Jared Brashears |
Katie Gunkelman |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Austin Thevenot |
americantreeservice03@gmail.com |
Owner |
Holstein |
Ida |
Iowa |
Jared Brashears |
Katie Gunkelman |
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 |
808 |
2023-11-08 07:37 |
Anonymous (not verified) |
94.188.207.229 |
Cush Comfort |
1225 e. River Dr STE 206 Davenport IA 52803 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2023-10-30 |
Chris Cushman |
ccushman82@gmail.com |
Milan |
IL |
United States |
Deena Maurus |
Jenna Ortberg |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher Cushman |
ccushman82@gmail.com |
Owner |
Milan |
IL |
United States |
Deena Maurus |
Jenna Ortberg |
Signed |
189 |
2021-02-25 10:56 |
Anonymous (not verified) |
173.27.130.150 |
Southside Boat Club |
Post Office Box 674, Keokuk, Iowa 52632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-01 |
Kathryn L. Farris |
southsideboatclub@gmail.com |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeri Denise Asbridge |
Kerryasbridge1@mediacombb.net |
Treasurer |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
190 |
2021-02-25 10:57 |
Anonymous (not verified) |
173.27.130.150 |
Southside Boat Club |
Post Office Box 674, Keokuk, Iowa 52632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-01 |
Kathryn L. Farris |
southsideboatclub@gmail.com |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeri Denise Asbridge |
Kerryasbridge1@mediacombb.net |
Treasurer |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
191 |
2021-02-25 11:07 |
Anonymous (not verified) |
173.27.130.150 |
Southside Boat Club |
Post Office Box 674, Keokuk, Iowa 52632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-01 |
Karen Colleen Rude |
kacee61@hotmail.com |
Keokuk |
Lee |
Iowa |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeri Asbridge |
Kerryasbridge1@mediacombb.net |
Treasurer |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
192 |
2021-02-25 11:10 |
Anonymous (not verified) |
173.27.130.150 |
Southside Boat Club |
Post Office Box 674, Keokuk, Iowa 52632 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-02-01 |
Jeri Asbridge |
kerryasbridge1@mediacombb.net |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeri Asbridge |
Kerryasbridge1@mediacombb.net |
Treasurer |
Hamilton |
Illinois |
United States |
Roger D. Huston |
Janis Leann Wallingford |
Signed |
460 |
2022-05-02 10:00 |
Anonymous (not verified) |
73.9.3.194 |
ERLIN AVILA INC |
1940 N GREEN LN APT 2A PALATINE IL 60074 |
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 |
ERLIN AVILA INC |
dianalcandelaria@aol.com |
PALATINE |
COOK |
IL |
DIANA CANCELARIA |
DALILA VILLEGAS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ERLIN AVILA TORREZ |
dianalcandelaria@aol.com |
PRESIDENT |
PALATINE |
Illinois |
United States |
Diana L Candelaria |
DALILA VILLEGAS |
Signed |
54 |
2020-04-03 19:30 |
Anonymous (not verified) |
173.25.134.162 |
Luke Laxton |
1502 guthrie 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. |
2020-04-03 |
Luke Laxton |
kyekingstonl@gmail.com |
Des Moines |
Iowa |
United States |
Omer Okic |
Nicholas weber |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Luke Laxton |
kyekingstonl@gmail.com |
Owner |
Des Moines |
Iowa |
United States |
Omer Okic |
Nicholas weber |
Signed |
92 |
2020-06-30 13:46 |
Anonymous (not verified) |
50.82.87.122 |
Diamond Bath LLC |
3184 Berkshire Pkwy Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-01-01 |
Patricia Fisk |
diamondbathllc@gmail.com |
Clive |
Iowa |
United States |
Josh Fisk |
Tom Childes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Patricia Fisk |
diamondbathllc@gmail.com |
Owner/CEO |
Clive |
Iowa |
United States |
Josh Fisk |
Tom Childes |
Signed |
93 |
2020-06-30 13:48 |
Anonymous (not verified) |
50.82.87.122 |
Waterfall Design LLC |
3184 Berkshire Pkwy Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2020-01-01 |
John Lanscak III |
waterfalldesign3@gmail.com |
Clive |
Iowa |
United States |
Josh Fisk |
Tom Childes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
John Lanscak III |
waterfalldesign3@gmail.com |
owner/CEO |
Clive |
Iowa |
United States |
Josh Fisk |
Tom Childes |
Signed |
147 |
2020-12-29 13:57 |
Anonymous (not verified) |
208.38.231.99 |
CJ Construction |
2129N Zenith 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. |
2020-12-29 |
Christine Ekin John Ekin |
chrohn2009@yahoo.com |
Davenport |
Iowa |
United States |
Christine Ekin |
John J Ekin |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CJ Construction |
chrohn2009@yahoo.com |
Co Owner |
Davenport |
Iowa |
United States |
Christine Ekin |
John J Ekin |
Signed |
172 |
2021-01-26 19:02 |
Anonymous (not verified) |
173.17.8.56 |
Hutch's Parking Lot Sweeping |
5235 JENNIFER 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. |
(1) I reject the employers’ liability coverage. |
2021-01-26 |
Bill HUTCHINSON |
btnwhutch@aol.com |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
WHITNIE HUTCHINSON |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill HUTCHINSON |
btnwhutch@aol.com |
Self |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
WHITNIE HUTCHINSON |
Signed |
184 |
2021-02-20 15:18 |
Anonymous (not verified) |
75.162.213.162 |
MJM, INC. |
32345 - 200TH ST., DALLAS CENTER, IA 50063 |
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. |
2021-02-20 |
MICHAEL CONNOLLY |
MJMINC2000@AOL.COM |
Dallas Center |
Iowa |
United States |
Stephen L. Davis |
Jackson Plagge |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
MICHAEL CONNOLLY |
MJMINC2000@AOL.COM |
Vice President |
Dallas Center |
Iowa |
United States |
Stephen L. Davis |
Jackson Plagge |
Signed |
269 |
2021-05-25 20:25 |
Anonymous (not verified) |
174.71.12.114 |
The Town and Country Aqua Club of Council Bluffs |
15444 Cherry Tree Lane Council Bluffs, Iowa 51503 |
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. |
2021-05-25 |
David Alan Bergman |
dbrgmn@gmail.com |
Council Bluffs |
Iowa |
United States |
Brett Ford |
Sean Dunphy |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Alan Bergman |
dbrgmn@gmail.com |
Board Vice President |
Council Bluffs |
Iowa |
United States |
Brett Ford |
Sean Dunphy |
Signed |
277 |
2021-06-17 21:34 |
Anonymous (not verified) |
97.125.98.166 |
J. Bos Holdings |
10925 NE 23rd Ave Mitchellville, IA 50169 |
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. |
2021-06-17 |
Jeff Bos |
jeffbos1967@gmail.com |
Mitchellville |
Iowa |
United States |
Angela Bos |
Amy Bos |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jeff Bos |
jeffbos1967@gmail.com |
officer |
Mitchellville |
Iowa |
United States |
Angela Bos |
Amy Bos |
Signed |
321 |
2021-08-27 16:10 |
Anonymous (not verified) |
173.30.51.29 |
Diamond Bath LLC |
3184 Berkshire PKwy Clive, Iowa 50325 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2021-01-02 |
Patricia Fisk |
diamondbathllc@gmail.com |
Clive |
Iowa |
United States |
Joshua A Fisk |
John S Lanscak III |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Patricia Fisk |
diamondbathllc@gmail.com |
Owner/CEO |
Clive |
Iowa |
United States |
Joshua A Fisk |
John S Lanscak III |
Signed |
337 |
2021-09-16 21:28 |
Anonymous (not verified) |
173.17.8.56 |
Hutch's Parking Lot Sweeping Inc. |
5235 Jennifer 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. |
(1) I reject the employers’ liability coverage. |
2021-09-16 |
Bill E Hutchinson |
btnwhutch@aol.com |
Pleasant Hill |
Iowa |
Iowa |
Tracy Hutchinson |
Nic Hutchinson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill E Hutchinson |
btnwhutch@aol.com |
Same |
Pleasant Hill |
Iowa |
Iowa |
Tracy Hutchinson |
Nic Hutchinson |
Signed |
378 |
2022-01-03 15:16 |
Anonymous (not verified) |
217.180.230.157 |
True360, Inc. |
1805 Collaboration Place, Suite 1300, Ames, Iowa 50010 |
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. |
2022-01-03 |
Christopher James |
chris@true-360.com |
Ames |
Iowa |
United States |
Jesse Kisker |
Cody Kapka |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher James |
chris@true-360.com |
President and Chief Executive Officer |
Ames |
Iowa |
United States |
Jesse Kisker |
Cody Kapka |
Signed |
405 |
2022-02-14 10:36 |
Anonymous (not verified) |
207.199.239.234 |
My Nest Greenhouse |
1134-1600 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. |
2022-02-14 |
Patti Bogler |
mynest@fmctc.com |
Harlan |
Iowa |
Iowa |
Hallie Carroll |
Katrina Shea |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Patti Bogler |
mynest@fmctc.com |
owner |
Harlan |
Iowa |
Iowa |
Hallie Lynn Carroll |
Katrina Mae Shea |
Signed |
420 |
2022-03-04 13:58 |
Anonymous (not verified) |
209.180.36.109 |
Sani Enterprise LLC |
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. |
2022-03-04 |
Mustafa Keserovic |
MustafaKeserovic@gmail.com |
Ankeny |
Pokl |
Iowa |
Sandro Tadic |
Andrew Swanson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Sandro Tadic |
sanienterprise14@gmail.com |
Owner |
WEST DES MOINES |
Iowa |
United States |
Sandro Tadic |
Andrew swanson |
Signed |
423 |
2022-03-08 12:17 |
Anonymous (not verified) |
173.18.193.171 |
BARNES INC |
1214 40TH ST FORT MADISON IA 52627 |
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. |
2021-03-08 |
dwight barnes |
humburdautoservice455@gmail.com |
Fort Madison |
Iowa |
United States |
Tyson P Barnes |
Brandon L Barnes |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
dwight barnes |
humburdautoservice455@gmail.com |
President |
Fort Madison |
Iowa |
United States |
Tyson P Barnes |
Brandon L Barnes |
Signed |
441 |
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 |
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 |