Fillable Rejection of Coverage by Corporate Officers or Members (Colorado DORA)

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Rejection of Coverage by Corporate Officers or Members (Colorado DORA)

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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
Rejection of Coverage by Corporate Officers or
Members of a Limited Liability Company (LLC)
PART A
1. Type of Entity: Corporation Limited Liability Company (LLC)
2. Name of Corporation or LLC:
3. Mailing Address:
Street or P.O. Box, Unit/Suite
City State Zip
4. Email Address:
5. Nature of Business:
6. Federal Employer Identification Number: 7. Business Phone:
9. State of Incorporation or Organization:
8. Date of Incorporation or Organization:
10. Corporate Officers or LLC Members rejecting coverage:
Name
First Middle Last Suffix (Jr., Sr., III)
Title(s)
Percent of
Ownership/
Member Interest
11.
Number of
employees of
the business other than the officers or members listed above:
12A. Does your company h
ave workers' compensation insurance? Yes No
12
B. If you answered “Yes” to Question 12A, please include your workers’ compensation policy information
below and submit this completed form directly to your carrier. If you answered “No” to Question 12A,
please submit this completed form directly to the Colorado Division of Workers’ Compensation.
a. Insurance Carrier Name: b. Policy Number:
c. Effective Dates: From: To:
13. Certification:
I, , in my capacity as Corporate Secretary or LLC Manager of
Name of Corporate Secretary or LLC Manager
, certify that the above and attached information is correct and complete.
Name of Corporation or LLC
Signature of Corporate Secretary or LLC Manager Date
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.”
WC43 Rev 10/20 Page 1 of 4
(The business must be in Good Standing with
the Colorado Secretary of State)
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signature
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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
Rejection of Coverage by Corporate Officers or
Members of a Limited Liability Company (LLC)
PART B - Corporate Officer or LLC Member Questionnaire
IMPORTANT: A separate Part B MUST be completed by every person listed in Part A.
1. Name of Corporation or LLC:
2. Mailing Address:
Street or P.O. Box, Unit/Suite
City State Zip
First  Middle  Last  Sufx (Jr., Sr., III)
3. Officer or Member Name:
4. Corporate Officer Title:
5.
Business Phone:
6. Date Officer/Member Elected:
7. Duties performed for Corporation or LLC:
8. Mark ONE that applies:
I hereby elect to reject workers’ compensation insurance coverage based on C.R.S. § 8-41-202 (Non- agricultural).
By signing this form, you are acknowledging your rejection of all benets under the Workers’ Compensation
Act and that if you are hurt on the job, C.R.S. § 8-41-401(3) may limit your recovery to $15,000. You are further
acknowledging that you are an owner of at least 10% of the stock of the corporation or at least 10% of the
membership interest of the LLC at all times, and control, supervise or manage the business affairs of the corporation
or LLC. The election to reject workers’ compensation insurance as a corporate ofcer/LLC member must be
voluntary and cannot be a condition of your employment.
I hereby rescind my previously led rejection of coverage. 
Corporate Ofcer/LLC Member Signature  Date
9. Notary: If this form is being led with the Division of Workers’ Compensation, the signature of the
individual corporate ofcer or LLC member completing Part B must be notarized. If this form is being led
with your insurance carrier, please contact your insurance carrier to determine if they require this form to
be notarized.
Acknowledged before me this  day of , .
Notary Public
In and for County
and State.
My commission expires 
.
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, nes, 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.”
SEAL
WC43 Rev 10/20
Page 2 of 4
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signature
click to edit
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signature
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Instructions/Definitions
General Instructions: Complete all information. Type or legibly print. A separate questionnaire, Part B,
must be completed and attached for each officer/member rejecting coverage. Incomplete forms may not be 
processed and may be returned. Mail the forms by certified mail to the insurance carrier or the Division of 
Workers’ Compensation per the below mailing instructions.
The effective date of election is the day following receipt of said notice by the insurance carrier or the Division. 
If an officer or limited liability company member changes his/her election, a revised questionnaire must be filed.
Part A
1. Type of Entity: Check the appropriate box to indicate if the company is a corporation or a limited
liability company (LLC).
2. Name of Corporation or LLC: List the legal name of the corporation or LLC as filed with the
Secretary of State.
3. Mailing Address: List the complete business mailing address of the corporation or LLC including Street
or P.O. Box, Suite Number, City, State, and Zip Code.
4. Email Address: List the business email address of the corporation or LLC.
5. Nature of Business: Briefly describe the type and nature of business conducted by the corporation
or LLC.
6. Federal Employer Identification Number:  List the 9-digit Federal Employer Identification Number
assigned to the corporation or LLC by the Internal Revenue Service.
7. Business Phone: List the telephone number of the Corporate Secretary or LLC Manager signing Part A
of the form.
8. Date of Incorporation or Organization: List the date of incorporation for a corporation or the date of
filing of Articles of Organization for an LLC.
9. State of Incorporation or Organization: List the state where the corporation is incorporated or where the
LLC filed its Articles of Organization. If corporation or LLC was formed in another state, it must also be registered
and in Good Standing with the Colorado Secretary of State.
10. Corporate Officers or LLC Members rejecting coverage: List the full name of the person(s) rejecting
coverage. Please include first, middle, last, and suffix (if applicable). Include title or titles, and the percent of
corporate ownership or membership interest in the company for each corporate officer or LLC member
electing to reject workers’ compensation coverage. Under C.R.S. §8-41-202(4), “corporate officer” means “the
chairperson of the board, president, vice-president, secretary, or treasurer who is an owner of at least ten
percent of the stock of the corporation and who controls, supervises or manages the business affairs of the
corporation, as attested to by the secretary of the corporation at the time of the election.” Corporate officers
and LLC members must own at least 10% of the membership interest in the company at all times and
control, supervise or manage the business affairs of the limited liability company to be eligible to reject
coverage. Attach separate sheet if more space is needed. The total ownership on this form should add up to 100
percent.
11. Number of employees of the corporation or LLC other than officers or members listed above: List the
number of employees other than officers or members listed under #10. Any person who is an employee of the
corporation or LLC, who is not a corporate officer or LLC member electing to reject coverage, must be insured for
workers’ compensation.
12A. Does your company have workers’ compensation insurance? Place a check in the appropriate space
indicating whether the business has Workers’ Compensation insurance.
12B. If “Yes” to Question 12A, provide Workers’ Compensation insurance policy information: If your business
has Workers’ Compensation insurance, list the name of the insurance carrier, the complete current policy number, and
the effective dates of the current policy.
13. Certification: Only the Corporate Secretary or LLC Manager shall sign and date Part A certifying that the
information contained on the form is correct and complete. If a Corporate Secretary has not been named, the President
may sign in lieu of the Corporate Secretary. Type or legibly write the name of the Corporate Secretary or LLC
Manager and the name of the corporation or LLC.
WC43 Rev 10/20
Page 3 of 4
Part B, Corporate Ofcer or LLC Member Questionnaire
To be completed by each Ofcer or Member electing to reject workers’ compensation insurance coverage or 
rescinding a previous election.
1. Name of Corporation or LLC: List the legal name of the corporation or LLC as filed with the Secretary
of State.
2. Mailing Address: List the complete business mailing address of the corporation or LLC including Street
or P.O. Box, Suite Number, City, State, and Zip Code.
3. Officer or Member Name: List the name of the individual corporate officer or LLC member completing
Part B. List the full name of the person rejecting coverage. Please include first, middle, last, and suffix
(if applicable).
4. Corporate Officer Title: List the title of the individual corporate officer completing Part B. If an LLC
member is completing Part B, leave blank.
5. Business Phone:  List the business telephone number of the individual corporate officer or LLC member
completing Part B.
6. Date Officer/Member Elected:  List the date the individual corporate officer or LLC member completing
Part B was elected to the position.
7. Duties performed for Corporation or LLC: Briefly describe the specific duties performed for the
corporation or LLC by the individual corporate officer or LLC member completing Part B.
8. Mark ONE that a
pplies: Check the appropriate box to indicate if the individual corporate officer or LLC 
member completing Part B is rejecting worker’s compensation coverage or rescinding a previously filed
rejection of coverage. The individual rejecting coverage or rescinding coverage must sign and date Part B. If the
rescinding option is selected, Part A need not be completed.
9. Notary: If this form is being filed with the Division of Workers’ Compensation, the signature of the
individual corporate officer or LLC member completing Part B must be notarized.  If this form is being filed
with your insurance carrier, please contact your insurance carrier to determine if they require this form to
be notarized.
10. Copy of form: You may wish to keep a copy of all forms for your records before submitting the
original forms.
Mailing Instructions
Insured: If the corporation or LLC has a workers’ compensation insurance carrier, le this form by 
certied mail directly with your insurance carrier.
Noninsured: If there is no workers’ compensation insurance carrier, le this form by certied mail with the 
Division of Workers’ Compensation at the following address:
Division of Workers’ Compensation
Coverage Enforcement Unit
633 17th St., Suite 400
Denver, CO 80202-3626
303-
318-8700
WC43 Rev 10/20
Page 4 of 4
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Rejection of Coverage by Corporate Officers or Members (Colorado DORA)

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Completed 27 January 2021

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