452 |
2022-04-22 16:06 |
Anonymous (not verified) |
75.63.172.134 |
Tempus Builders, Inc. |
4331 Valley Ridge 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. |
2022-04-22 |
Scott Cooper |
scott@tempusbuilders.com |
Dallas |
TX |
United States |
Phil Sheumaker |
Cristen Cooper |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott Cooper |
scott@tempusbuilders.com |
President |
Dallas |
TX |
United States |
James Buckley |
Phil Sheumaker |
Signed |
453 |
2022-04-22 16:07 |
Anonymous (not verified) |
75.63.172.134 |
Tempus Builders, Inc. |
4331 Valley Ridge 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. |
2022-04-22 |
Jennifer Cooper |
scott@tempusbuilders.com |
Dallas |
TX |
United States |
Phil Sheumaker |
Cristen Cooper |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Scott Cooper |
scott@tempusbuilders.com |
President |
Dallas |
TX |
United States |
James Buckley |
Phil Sheumaker |
Signed |
454 |
2022-04-26 14:03 |
Anonymous (not verified) |
216.106.225.224 |
Kevin Knapp |
2227 120th 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. |
2022-04-26 |
Nathan Glenn Knapp |
knapptimedairy@gmail.com |
larchwood |
lyon |
ia |
Eric TeGrootenhuis |
Lisa Faber |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Kevin Knapp |
knapptimedairy@gmail.com |
owner |
Larchwood |
Iowa |
United States |
Eric TeGrootenhuis |
Lisa Faber |
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 |
456 |
2022-04-29 08:14 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West Ave. Baxter, IA 50028 |
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 |
Matthew Lee Wells |
Praynostop@msn.com |
Des Moines |
Polk |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rick Thatcher |
rickswrecks@gmail.com |
President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
457 |
2022-04-29 08:21 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West ave Baxter, IA 50028 |
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 |
Nathan Doubek |
thatcherautocenter@gmail.com |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rick Thatcher |
rickswrecks@gmail.com |
President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
458 |
2022-04-29 08:26 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West ave Baxter Iowa 50028 |
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 |
Richard Thatcher |
rickswrecks@gmail.com |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Nathan Doubek |
thatcherautocenter@gmail.com |
Vice President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
459 |
2022-04-29 08:49 |
Anonymous (not verified) |
107.126.24.57 |
Thatcher Auto Center INC |
406 S West ave Baxter. IA 50028 |
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. |
2022-02-15 |
David Kirkman |
kirkcola@gmail.com |
Newton |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Rick Thatcher |
rickswrecks@gmail.com |
President |
Baxter |
Jasper |
Iowa |
Joel Schabilion |
Al Nuzum |
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 |
461 |
2022-05-02 11:08 |
Anonymous (not verified) |
192.119.212.86 |
Iceberg Enterprises LLC |
101 E. 1st street Arthur IA 51431 |
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 |
Jesse Bergman |
jk_montana@yahoo.com |
arthur |
Iowa |
United States |
Maren Smith |
Darren Smith |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Katherine Bergman |
jk_montana@yahoo.com |
Owner |
Arthur |
IOWA |
United States |
Susan Bergman |
Jesse Bergman |
Signed |
462 |
2022-05-02 16:01 |
Anonymous (not verified) |
71.39.227.238 |
IN SEASON LAWN CARE LLC |
32841 HOMESTEAD DR, GRANGER, IA 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. |
2022-05-02 |
JOSEPH CRAIG COVER |
inseason98@gmail.com |
Granger |
Dallas |
Iowa |
Abbey Luellen |
Steve Phillips |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Joseph Craig Cover |
inseason98@gmail.com |
Owner |
Granger |
Dallas |
Iowa |
Abbey Luellen |
Steve Phillips |
Signed |
463 |
2022-05-02 16:02 |
Anonymous (not verified) |
71.39.227.238 |
IN SEASON LAWN CARE LLC |
32841 HOMESTEAD DR, GRANGER, IA 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. |
2022-05-02 |
CHEYENNE COVER |
inseason98@gmail.com |
Granger |
Dallas |
Iowa |
Abbey Luellen |
Steve Phillips |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CHEYENNE Cover |
inseason98@gmail.com |
Owner |
Granger |
Dallas |
Iowa |
Abbey Luellen |
Steve Phillips |
Signed |
464 |
2022-05-06 10:15 |
Anonymous (not verified) |
172.86.44.178 |
Cornhill Express LLC |
6472 40th St, Aurora, IA 50607 |
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. |
2022-05-06 |
Jamie Fettkether |
sales@cherepair.com |
Aurora |
Buchanan |
Iowa |
Ben Hogan |
Ryan Peyton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Jamie Fettkether |
sales@cherepair.com |
Owner |
Aurora |
Buchanan |
Iowa |
Ben Hogan |
Ryan Peyton |
Signed |
465 |
2022-05-08 19:08 |
Anonymous (not verified) |
173.27.224.202 |
Vail Foundations |
1508 West Clinton Ave Indianola, Iowa 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. |
2022-05-08 |
Cory Vail |
vailfoundations@gmail.com |
Indianola |
Warren |
Iowa |
Monica Vaik |
James Vail |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Cory James Vail |
vailfoundations@gmail.com |
President |
Indianola |
Warren |
Iowa |
Monica Vail |
James Vail |
Signed |
466 |
2022-05-09 10:52 |
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. |
2022-05-09 |
Claude Riley |
Rileybuddy58@gmail.com |
Johnston |
Polk |
Iowa |
Andrew Swanson |
Claude Riley |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrew Swanson |
sanienterprise14@gmail.com |
Director of Operations |
Granger |
Dallas |
Iowa |
Andrew Swanson |
Sandro Tadic |
Signed |
467 |
2022-05-09 10:54 |
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. |
2022-05-09 |
Safet Derguti |
safetigo@hotmail.com |
Des Moines |
Polk |
Iowa |
Andrew Swanson |
Sandro Tadic |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Andrew Swanson |
sanienterprise14@gmail.com |
Director of Operations |
Granger |
Dallas |
Iowa |
Andrew Swanson |
Sandro Tadic |
Signed |
470 |
2022-05-12 14:28 |
Anonymous (not verified) |
173.184.134.123 |
Bryce Hoffert LLC |
1802 Lake Street Emmetsburg Iowa 50536 |
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. |
2022-05-12 |
Bryce C Hoffert |
brycehoffertllc@gmail.com |
Emmetsburg |
Pala Alto |
Iowa |
Ray Hoffert |
Shelbie Hurdle |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bryce Hoffert |
brycehoffertllc@gmail.com |
member |
Emmetsburg |
Palo Alto |
Iowa |
Ray Hoffert |
Shelbie Hurdle |
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 |
472 |
2022-05-13 11:19 |
Anonymous (not verified) |
69.18.19.139 |
BES, Inc. |
1615 E Washington St, Mt Pleasant, IA 52641 |
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. |
2022-05-13 |
Todd Baldridge |
todd.baldridge@beswatersolutions.com |
West Branch |
Cedar |
Iowa |
Nicholas Baldridge |
Owen Baldridge |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Randy Seberg |
randy.seberg@beswatersolutions.com |
Managing Director |
Mt Pleasant |
Henry |
IA |
John Rodewald |
Matt Mowery |
Signed |
473 |
2022-05-16 14:20 |
Anonymous (not verified) |
167.142.231.34 |
Trust Builders, LLC |
1055 Jordan Creek Parkway, Suite 200, West Des Moines, IA 50226 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-16 |
Christopher Dean Petersen |
chrispetersen@trustbuildersiowa.com |
Polk City |
Polk |
Iowa |
Curtis William Blake |
Joseph Duane Meints |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Christopher Dean Petersen |
chrispetersen@trustbuildersiowa.com |
Owner |
Polk City |
Polk |
Iowa |
Curtis William Blake |
Joseph Duane Meints |
Signed |
474 |
2022-05-16 16:25 |
Anonymous (not verified) |
208.126.193.1 |
Gentle Bend Inc. |
1075 120th Street, Wellman, Iowa 52356 |
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. |
2022-05-16 |
Georgia Gent |
ggent83@gmail.com |
Wellman |
Washington |
Iowa |
Jeff Spenner |
Shawn Powell |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Georgia Gent |
ggent83@gmail.com |
owner |
Wellman |
Washington |
Iowa |
Jeff Spenner |
Shawn Powell |
Signed |
475 |
2022-05-19 10:11 |
Anonymous (not verified) |
172.86.13.54 |
BOLT HOLDINGS Inc. and Holt Precision dba Holt Bladeworks and Holt Kinetic Solutions |
3230 N. Center Point Rd Unit 204, 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. |
2022-05-19 |
Angey Holt |
Angey@Holtkineticsolutions.com |
Robins |
Linn |
Iowa |
Lisa Gleason |
Danielle Congleton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Gleason |
Lisa@holtkineticsolutions.com |
General Manager |
Marion |
Linn |
Iowa |
Danielle Congleton |
Joe Holt |
Signed |
476 |
2022-05-19 11:45 |
Anonymous (not verified) |
172.86.13.54 |
BOLT HOLDINGS Inc. and Holt Precision dba Holt Bladeworks and Holt Kinetic Solutions |
3230 N. Center Point Rd Unit 204, 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. |
2022-05-19 |
Joseph Holt |
Joe@kineticsolutons.com |
Robins |
Linn |
Iowa |
Lisa Gleason |
Danielle Congleton |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Gleason |
Lisa@holtkineticsolutions.com |
General Manager |
Marion |
Linn |
Iowa |
Danielle Congleton |
Angey Holt |
Signed |
477 |
2022-05-19 11:49 |
Anonymous (not verified) |
172.86.13.54 |
BOLT HOLDINGS Inc. and Holt Precision dba Holt Bladeworks and Holt Kinetic Solutions |
3230 N. Center Point Rd Unit 204, 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. |
2022-05-19 |
Ben Congleton |
Ben@holtkineticsolutions.com |
Cedar Rapids |
Linn |
Iowa |
Lisa Gleason |
Angey Holt |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa Gleason |
Lisa@holtkineticsolutions.com |
General Manager |
Marion |
Linn |
Iowa |
Lisa Gleason |
Danielle Congleton |
Signed |
478 |
2022-05-24 13:16 |
Anonymous (not verified) |
63.146.149.12 |
EBN CONSTRUCTION LLC |
314 NE 5TH ST, ANKENY IA 50021 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-05-24 |
Juan J Perez Munoz |
ebnconstruction@icloud.com |
Des Moines |
Polk |
Iowa |
Jaime Leiva |
Kevin Pham |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Juan J Perez Munoz |
ebnconstruction@icloud.com |
Owner |
Des MOines |
Polk |
Iowa |
Jaime Leiva |
Kevin Pham |
Signed |
479 |
2022-05-26 14:05 |
Anonymous (not verified) |
71.28.218.225 |
TRAER MUSEUM |
514 2ND ST. TRAER, IA 50675 |
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. |
2022-05-26 |
Carol Boyce |
carolwoodboyce@gmail.com |
Dysart |
Tama |
IOWA |
EDWARD HOEG |
KIM DAHMS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
CAROL BOYCE |
carolwoodboyce@gmail.com |
VICE PRESIDENT |
Dysart |
Tama |
IOWA |
ED HOEG |
KIM DAHMS |
Signed |
480 |
2022-05-30 11:37 |
Anonymous (not verified) |
134.215.6.237 |
Access Property Management Corp DBA Wine & Spirits |
510 E Carrington Ln, Appleton, WI 54913 |
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. |
2022-05-30 |
Lisa M Ricklefs |
lisarick19@yahoo.com |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Thomas Ricklefs |
tjrick@yahoo.com |
President |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferak |
Signed |
481 |
2022-05-30 11:42 |
Anonymous (not verified) |
134.215.6.237 |
Access Property Management Corp DBA Wine & Spirits |
510 E Carrington Ln, Appleton, WI 54913 |
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. |
2022-05-30 |
Thomas J Ricklefs |
tjrick@yahoo.com |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Lisa M Ricklefs |
lisarick19@yahoo.com |
VP |
Appleton |
Outagamie |
WI |
Jeff Fonferek |
Melissa Fonferek |
Signed |
482 |
2022-06-02 08:25 |
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. |
2022-05-24 |
Bill Brookhiser |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Bill Brookhiser |
judy@fullenkampins.com |
Board Member |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
483 |
2022-06-02 08:28 |
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. |
2022-05-24 |
Deb Sylvester |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Deb Sylvester |
judy@fullenkampins.com |
Secretary / Treasurer |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
484 |
2022-06-02 08:31 |
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. |
2022-05-24 |
Gregory Liddle |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
judy moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Gregory Liddle |
judy@fullenkampins.com |
President |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
485 |
2022-06-02 08:33 |
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. |
2022-05-24 |
Hugh Vandgriff |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Hugh Vandegriff |
Judy@fullenkampins.com |
board member |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
486 |
2022-06-02 08:34 |
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. |
2022-05-24 |
Craig Pieper |
judy@fullenkampins.com |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Craig Pieper |
Judy@fullenkampins.com |
Vice President |
Wever |
Lee |
Iowa |
Chris Fullenkamp |
Judy Moeller |
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 |
488 |
2022-06-02 13:06 |
Anonymous (not verified) |
96.31.21.223 |
Lamfers Farm Inc |
2161 Jackson Ave George IA 51237 |
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. |
2022-05-23 |
Roger Lamfers |
rclamfers@gmail.com |
George |
Lyon |
Iowa |
Shannon Monson |
Teresa Hoogendoorn |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Roger Lamfers |
rclamfers@gmail.com |
President |
George |
Lyon |
Iowa |
Shannon Monson |
Teresa Hoogendoorn |
Signed |
489 |
2022-06-02 13:09 |
Anonymous (not verified) |
96.31.21.223 |
Lamfers Farm Inc |
2161 Jackson Ave George IA 51237 |
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. |
2022-05-23 |
Charnele Lamfers |
rclamfers@gmail.com |
George |
Lyon |
Iowa |
Shannon Monson |
Teresa Hoogendoorn |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Roger Lamfers |
rclamfers@gmail.com |
President |
George |
Lyon |
Iowa |
Shannon Monson |
Teresa Hoogendoorn |
Signed |
490 |
2022-06-03 10:14 |
Anonymous (not verified) |
70.96.153.153 |
Reicks Construction Inc |
5415 Alburnett Rd, 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. |
2022-06-03 |
Victor Reicks |
victor@optionsexteriors.com |
Marion |
Linn County |
Iowa |
Austin Miller |
Charlotte Rasmussen |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Victor Reicks |
victor@optionsexteriors.com |
Owner |
Marion |
Linn County |
Iowa |
Austin Miller |
Charlotte Rasmussen |
Signed |
491 |
2022-06-06 09:32 |
Anonymous (not verified) |
24.118.76.144 |
Minnesota Restoration Contractors Inc. DBA MNRC |
12252 Nicollet Ave Burnsville, MN 55337 |
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 |
Daniel Lewis Lillestol |
info@mnrcinc.com |
Wayzata |
MN |
United States |
Karina Bazhenova |
MICHELLE LILLESTOL |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Daniel Lewis Lillestol |
info@mnrcinc.com |
CEO |
Wayzata |
Hennnepin |
MN |
Karina Bazhenova |
MICHELLE LILLESTOL |
Signed |
492 |
2022-06-06 20:18 |
Anonymous (not verified) |
69.54.109.51 |
R C TRUCKING, LTD. |
16125 310th Street, Mason City, Iowa 50401 |
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 |
ROGER CHIZEK |
joldoak@gmail.com |
MASON CITY |
Iowa |
United States |
Kathy Zobrist |
Alan Zobrist |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
ROGER CHIZEK |
joldoak@gmail.com |
President |
MASON CITY |
Iowa |
United States |
Kathy Zobrist |
Alan Zobrist |
Signed |
493 |
2022-06-08 13:00 |
Anonymous (not verified) |
173.31.148.43 |
OKOBOJI PERFORMING ARTS |
97 WOODLIN DR MILFORD, IA 51351 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-06 |
JESSICA SCHABLE |
JESS@OKOBOJIPERFORMINGARTS.COM |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
JESSICA SCHABLE |
JESS@OKOBOJIPERFORMINGARTS.COM |
SELF |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
494 |
2022-06-08 13:04 |
Anonymous (not verified) |
173.31.148.43 |
OKOBOJI PERFORMING ARTS |
97 WOODLIN DR MILFORD, IA 51351 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-08 |
JOHN MOORE |
JOHN@OKOBOJIPERFORMINGARTS.COM |
MINNEAPOLIS |
HENNEPIN |
MN |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
JOHN MOORE |
JOHN@OKOBOJIPERFORMINGARTS.COM |
SELF |
MINNEAPOLIS |
HENNEPIN |
MN |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
495 |
2022-06-08 13:07 |
Anonymous (not verified) |
173.31.148.43 |
OKOBOJI PERFORMING ARTS |
97 WOODLIN DR MILFORD, IA 51351 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-08 |
DREW DUNCAN |
DREW@OKOBOJIPERFORMINGARTS.COM |
LINCOLN |
LANCASTER |
NE |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
DREW DUNCAN |
DREW@OKOBOJIPERFORMINGARTS.COM |
SELF |
LINCOLN |
LANCASTER |
NE |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
496 |
2022-06-15 10:11 |
Anonymous (not verified) |
50.81.253.108 |
WALLICK FAMILY TRUCKING INC |
2374 UNION AVE, VILLISCA, IA 50864 |
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. |
2022-06-15 |
JUSTIN WALLICK |
SCRALL@PARTNERSINS.COM |
VILLISCA |
MONTGOMERY |
IOWA |
JAMES S CRALL |
RICHARD D CRALL |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
JUSTIN WALLICK |
SCRALL@PARTNERSINS.COM |
PRESIDENT |
VILLISCA |
MONTGOMERY |
IOWA |
JAMES S CRALL |
RICHARD D CRALL |
Signed |
497 |
2022-06-16 11:09 |
Anonymous (not verified) |
72.10.21.42 |
Babcock Services Idaho, Inc. |
8113 W QUINAULT AVENUE 201, KENNEWICK, WA 99336 |
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. |
2022-06-01 |
WALLACE KENNEDY |
wkennedy@babcockservices.com |
Richland |
Benton |
Washington |
Angie Jimenez |
Karen Patterson |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Carmen Clyde |
cclyde@babcockservices.com |
Secretary |
Kennewick |
Benton |
Washington |
Angie Jimenez |
Karen Patterson |
Signed |
498 |
2022-06-17 08:45 |
Anonymous (not verified) |
64.5.79.180 |
The Sign Shed & Graphics LLC |
529 Erie St, PO Box 252 |
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. |
2022-05-26 |
Brent Ulrich |
signshed@yahoo.com |
Storm Lake |
IA |
United States |
Zach Ruroden |
Ryan Young |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Brent Ulrich |
signshed@yahoo.com |
CEO |
Storm Lake |
IA |
United States |
Zach Ruroden |
Ryan Young |
Signed |
499 |
2022-06-22 03:40 |
Anonymous (not verified) |
64.251.168.116 |
VALBURG AERIAL SPRAYING INC. |
27656 SD Hwy 44 WHITE RIVER SD 57579 |
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. |
2022-06-19 |
Dan A Valburg |
agflyer620@gwtc.net |
White River |
SD |
SD |
LANDON HOSSLE |
JOSH HICKS |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
Dan A Valburg |
agflyer620@gwtc.net |
PRESIDENT |
White River |
SD |
SD |
LANDON HOSSLE |
JOSH HICKS |
Signed |
500 |
2022-06-22 15:55 |
Anonymous (not verified) |
206.125.132.254 |
Cozad Trucking Inc |
2272 W River Dr, Davenport, IA 52802 |
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. |
2022-06-22 |
David Cozad |
jeepd856@gmail.com |
Davenport |
Scott |
Iowa |
Brett Nelson |
Colleen Heiser |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
David Cozad |
jeepd856@gmail.com |
Owner |
Davenport |
Scott |
IA |
Brett Nelson |
Colleen Heiser |
Signed |
502 |
2022-06-24 12:15 |
Anonymous (not verified) |
173.31.148.43 |
HISTORIC ARNOLDS PARK INC |
37 LAKE ST ARNOLDS PARK, IA 51331 |
I understand that by signing this statement I reject the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my rejection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of my employment with the corporation. |
I also understand that by signing this statement and checking alternative (1) below I reject employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of employment with the corporation. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement of Corporation," below by an authorized agent of the corporation rejects for the corporation employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the corporation. |
(1) I reject the employers’ liability coverage. |
2022-06-24 |
GARY RAY |
GARYJRAY70@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The corporation rejects the employers’ liability coverage. |
JON PAUSLEY |
JON@ARNOLDSPARK.COM |
CEO |
MILFORD |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
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 |
504 |
2022-06-30 17:18 |
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 |
Timothy Roberts |
roberts.timoty2@gmail.com |
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 |