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  1. Termination of Rejection of Workers' Compensation or Employers' Liability Coverage
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Termination of Rejection of Workers' Compensation or Employers' Liability Coverage

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Showing 1 - 12 of 12.   Show 10 | All results per page.
# Submitted User IP address Name of Corporation: Address of Corporation's Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Statement 4 Agreement: Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness 1: Full Name of Witness 2: Signing Indication: Termination Agreement: Full Name of Authorized Agent: Email: Relationship to Corporation: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signed Indication:
14 2023-08-28 08:22 Anonymous (not verified) 94.188.207.228 gibson clover house llc 601 South roosevelt suite 101 I previously made a written rejection of workers’ compensation or employers’ liability coverage. I understand that by signing this termination, I will terminate the rejection of coverage that I previously signed and filed. I also understand that after signing and filing this termination, my status will be the same as if the rejection of coverage had not been made. I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. 2023-08-28 zac gayewski zgay187@outlook.com burlington Des Moines IA Sandra Lee Broeg Edwin Malone Signed The corporation terminates the prior rejection the employers’ liability coverage. zac r gayewski zgay187@outlook.com president burlington Des Moines IA Sandra Lee Broeg Edwin Malone Signed
13 2023-03-28 12:10 Anonymous (not verified) 94.188.205.174 Fleming Nursery, Inc 7900 Pederman LN, Cedar Rapids, IA 52411 I previously made a written rejection of workers’ compensation or employers’ liability coverage. I understand that by signing this termination, I will terminate the rejection of coverage that I previously signed and filed. I also understand that after signing and filing this termination, my status will be the same as if the rejection of coverage had not been made. I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. 2023-03-28 Gina Reynolds ginascope@aol.com Cedar Rapids Linn Iowa Peg Fraser Christa Payne Signed The corporation terminates the prior rejection the employers’ liability coverage. Gina Reynolds ginascope@aol.com Owner Cedar Rapids Linn Iowa Peg Fraser Christa Payne Signed
12 2023-03-28 12:08 Anonymous (not verified) 94.188.205.166 Fleming Nursery, INC 7900 Pederman LN, Cedar Rapids, IA 52411 I previously made a written rejection of workers’ compensation or employers’ liability coverage. I understand that by signing this termination, I will terminate the rejection of coverage that I previously signed and filed. I also understand that after signing and filing this termination, my status will be the same as if the rejection of coverage had not been made. I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. 2023-03-28 Matt Reynolds NURSERYMATT@AOL.COM Cedar Rapids Linn Iowa Peg Fraser Christa Payne Signed The corporation terminates the prior rejection the employers’ liability coverage. Matt Reynolds nurserymatt@aol.com Owner Cedar Rapids Linn Iowa Peg Fraser Christa Payne Signed
11 2023-03-28 08:59 Anonymous (not verified) 94.188.205.176 Donald Reinig 1119 e Madison Des Moines, IA 50313 I previously made a written rejection of workers’ compensation or employers’ liability coverage. I understand that by signing this termination, I will terminate the rejection of coverage that I previously signed and filed. I also understand that after signing and filing this termination, my status will be the same as if the rejection of coverage had not been made. I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. 2023-03-28 Donald Reinig donny@smartind.com Des Moines Polk iowa Robin Russo Tina Owens Signed The corporation terminates the prior rejection the employers’ liability coverage. Donald Reinig donny@smartind.com self Des Moines Polk Iowa Robin Russo Tina Owens Signed
10 2023-03-28 08:53 Anonymous (not verified) 94.188.207.227 Riita Littrell 620 N 9th Street Carlisle, ia 50047 I previously made a written rejection of workers’ compensation or employers’ liability coverage. I understand that by signing this termination, I will terminate the rejection of coverage that I previously signed and filed. I also understand that after signing and filing this termination, my status will be the same as if the rejection of coverage had not been made. I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. 2023-03-28 Rita Littrell partsdept@smartind.com Carlisle Warren IA Robin Russo Tina Owens Signed The corporation terminates the prior rejection the employers’ liability coverage. Rita Litrell partsdept@smartind.com self Carlisle Warren Iowa Robin Russo Tina Owens Signed
9 2023-03-28 08:42 Anonymous (not verified) 94.188.205.177 James Chitty 307 2nd st colo, ia 50056 I previously made a written rejection of workers’ compensation or employers’ liability coverage. I understand that by signing this termination, I will terminate the rejection of coverage that I previously signed and filed. I also understand that after signing and filing this termination, my status will be the same as if the rejection of coverage had not been made. I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. 2023-03-28 James Chitty techsupport@smartind.com Colo Story Iowa Robin Russo Tina Owens Signed The corporation terminates the prior rejection the employers’ liability coverage. James Chitty techsupport@smartind.com self colo story iowa Robin Russo Tina Owens Signed
8 2023-03-23 10:59 Anonymous (not verified) 94.188.205.167 Rita Littrell 620 N. 9th St. I previously made a written rejection of workers’ compensation or employers’ liability coverage. I understand that by signing this termination, I will terminate the rejection of coverage that I previously signed and filed. I also understand that after signing and filing this termination, my status will be the same as if the rejection of coverage had not been made. I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. 2023-03-23 Rita Littrell ritaf1966@gmail.com Carlisle Warren Iowa Kim Owens Tina Owens Signed The corporation terminates the prior rejection the employers’ liability coverage. Rita Littrell ritaf1966@gmail.com myself Carlisle Warren Iowa Kim Owens Tina Owens Signed
7 2023-03-22 11:28 Anonymous (not verified) 94.188.205.169 Shane Squires 702 2nd Ave SW Altoona, Iowa 50009 I previously made a written rejection of workers’ compensation or employers’ liability coverage. I understand that by signing this termination, I will terminate the rejection of coverage that I previously signed and filed. I also understand that after signing and filing this termination, my status will be the same as if the rejection of coverage had not been made. I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. 2023-03-22 Shane Squires shanesq411@gmail.com Altoona Polk Iowa Tina Owens Steve Wimer Signed The corporation terminates the prior rejection the employers’ liability coverage. Shane Squires shanesq411@gmail.com self Altoona Polk Iowa Tina Owens Steve Wimer Signed
6 2023-03-22 11:23 Anonymous (not verified) 94.188.207.224 TRACY SCALES 1920 FRANKLIN AVE I previously made a written rejection of workers’ compensation or employers’ liability coverage. I understand that by signing this termination, I will terminate the rejection of coverage that I previously signed and filed. I also understand that after signing and filing this termination, my status will be the same as if the rejection of coverage had not been made. I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. 2022-03-21 TRACY SCALES tracy.walker69@gmail.com DES MOINES POLK IOWA TINA OWNES JAMES CHITTY Signed The corporation terminates the prior rejection the employers’ liability coverage. TRACY SCALES tracy.walker69@gmail.com self DES MOINES POLK DES MOINES TINA OWNES JAMES CHITTY Signed
5 2023-03-22 11:21 Anonymous (not verified) 94.188.207.230 Kimberly Owens 2305 E 19th St N lot 109 Newton Ia 50208 I previously made a written rejection of workers’ compensation or employers’ liability coverage. I understand that by signing this termination, I will terminate the rejection of coverage that I previously signed and filed. I also understand that after signing and filing this termination, my status will be the same as if the rejection of coverage had not been made. I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. 2023-03-22 Kimberly Owens kimmybobby1220@gmail.com Newton IOWA United States Tina Owens James Chitty Signed The corporation terminates the prior rejection the employers’ liability coverage. Kimberly M Owens kimmybobby1220@gmail.com Self Newton Jasper United States Tina Owens James Chitty Signed
4 2023-03-22 11:15 Anonymous (not verified) 94.188.207.225 Dora Valadez 1244 E 32nd Street Des Moines, IA 50317 I previously made a written rejection of workers’ compensation or employers’ liability coverage. I understand that by signing this termination, I will terminate the rejection of coverage that I previously signed and filed. I also understand that after signing and filing this termination, my status will be the same as if the rejection of coverage had not been made. I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. 2023-03-22 Dora Valadez towens@smartind.com Des Moines Polk Iowa Tina Owens Steve Wimer Signed The corporation terminates the prior rejection the employers’ liability coverage. Dora Valadez towens@smartind.com self Des Moines Polk Iowa Tina Owens Steve Wimer Signed
3 2023-03-21 13:32 Anonymous (not verified) 94.188.205.175 Tina Owens 4162 Hwy F62 West Monroe, IA 50170 I previously made a written rejection of workers’ compensation or employers’ liability coverage. I understand that by signing this termination, I will terminate the rejection of coverage that I previously signed and filed. I also understand that after signing and filing this termination, my status will be the same as if the rejection of coverage had not been made. I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed. 2023-03-21 Tina Owens towens974447@yahoo.com Monroe Jasper Iowa Kim Owens Steve Wimer Signed The corporation terminates the prior rejection the employers’ liability coverage. Tina Owens towens974447@yahoo.com SELF Monroe Jasper Iowa Kim Owens Steve Wimer Signed