Fillable Officials Exclusion of Uncompensated (Colorado DORA)

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Officials Exclusion of Uncompensated (Colorado DORA)

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Colorado Department of Regulatory Agencies (DORA) is responsible for professional licensing and consumer protection in Colorado USA.

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1
Instructions for Completing the
Exclusion of Uncompensated
Officials
Please read all pages
This form is “fillable.” That means you can type the information onto
the form from your computer and print the form. You will not be able
to save the form onto your computer’s hard drive.
When you open the form, click in the “Name of Agency” box (field),
and use the tab key to navigate to the next field. Do not use the Enter
key; pressing the Enter key will only page down. Each field has been
limited. This means that you cannot continue to type information into
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to fill in the fields for Official’s Social Security # and
Business Phone #. Do not use dashes or parentheses; when you tab
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WC44 Rev 02/12
Department of Labor and Employment
Division of Workers’ Compensation
633 17th St., Suite 400, Denver, CO 80202-3626
Telephone: 303.318.8640 Fax: 303.318.8739
EXCLUSION OF UNCOMPENSATED PUBLIC OFFICIALS
Name of Agency: __________________________________________________________________________________
Federal Employer Identification # (FEIN): __________________________Business Phone #: (______)______________
Mailing Address: __________________________________________________________________________________
Street or P.O. Box / Suite #
________________________________________________________________________________________________
City State Zip
If Self-Insured Employer, enter the Permit Number: _______________________________________________________
If not Self-Insured, enter the workers’ compensation insurance carrier name and policy number:
________________________________________________________________________________________________
Insurance Carrier Name Policy Number
Upcoming Policy Period: From: _________________ To: ________________________
Month / Year Month / Year
List the Governing Body for the Agency, Category of uncompensated officials (i.e. board, commission, etc.) or any
combination of categories of such officials that you are opting to exclude from coverage for the upcoming policy year
and Names of Officials (Attach additional pages if needed):
Name of Governing Body: __________________________________________________________________________
Category
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Name of Official
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
C.R.S. section 8-40-202(1)(a)(I)(B) provides an option to exclude from workers’ compensation insurance coverage
uncompensated elected or appointed officials. You must promptly notify each official of your exercise of the option to
exclude them. This form must be filed with the Division of Workers’ Compensation not less than forty-five (45) days before
the start of the policy period for which the option is to be exercised. Attach governing body’s resolution.
By signing this form, you are certifying that the above-named uncompensated, elected or appointed public officials are
designated to be excluded from worker’s compensation coverage for the upcoming policy year, pursuant to C.R.S. section
8-40-202(1)(a)(I)(B). You are also certifying that these officials have been notified of this exclusion.
Signature: ______________________________________________________________________________________
Print Name: _____________________________________________________________________________________
Date: __________________ Title: ___________________________________________________________________
Submit this form with the Governing Body’s Resolution to: Division of Workers’ Compensation, Coverage
Enforcement Unit, 633 17th St., Suite 400, Denver, CO 80202-3626. If insured, please make a copy of this
completed form and send it to your insurance carrier. If you have any questions, contact the Division of Workers’
Compensation Customer Service Unit at 303.318.8700.
C.R.S. section 10-1-128(6)(a) states: “ It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance,
and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or
information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a
settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of
Regulatory Agencies.”
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Officials Exclusion of Uncompensated (Colorado DORA)

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Completed 27 January 2021

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