Fillable Rejection of Coverage by Partners and Sole Proprietors (Colorado DORA)

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Rejection of Coverage by Partners and Sole Proprietors (Colorado DORA)

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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
Rejection of Coverage by Partners and Sole Proprietors
Performing Construction Work on Construction Sites
PART A
1. Type of Entity: NOTE: Sole Proprietors and
General Partnerships MUST have
a TRADE NAME registered with
the Colorado Secretary of State.
2. True Name of Business:
3. Registered Trade Name (if applicable):
4. Mailing Address:
Street or P.O. Box, Unit/Suite
City
State
Zip
7. Business Phone:
5. Email Address:
6. Federal Employer Identification Number:
8. Date of Registration of Trade Name or Partnership with the Colorado Secretary of State
9. Nature of work performed on construction sites:
10. Sole Proprietor or Partner(s) rejecting coverage (attach a separate sheet if necessary):
Name
Title (e.g. Sole Proprietor, General
First Middle Last Suffix (Jr., Sr., III)
Partner, or Limited Partner
11. Number of employees of the business other than the Sole Proprietor or Partners listed above:
12. Submitted by:
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.”
WC45 Rev 10/20
Page 1 of 4
Sole Proprietorship
General Partnership (GP)
Limited
Partnership (LP)
Limited Liability Partnership (LLP)
Limited Liability Limited Partnership (LLLP)
Name
Title
Date
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
Rejection of Coverage by Partners and Sole Proprietors
Performing Construction Work on Construction Sites
PART B - Sole Proprietor or Partner Questionnaire
IMPORTANT: A separate Part B MUST be completed by every person listed in Part A.
1. Sole Proprietor/Partner Name:
First  Middle  Last  Sufx
2. Title (e.g. Sole Proprietor, General
Partner, or Limited Partner)
3. Business Phone
:
4A. If Sole Proprietor: Date Business Started:
4B. If Partner: Date Became Partner:
Street or P.O. Box, Unit/Suite
City State Zip
5. True Name of Business:
6. Trade Name (if applicable):
7. Mailing Address:
8. Mark ONE that applies:
I hereby elect to reject workers’ compensation insurance coverage based on C.R.S. § 8-41-404.
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. The election to reject
workers’ compensation insurance as a sole proprietor/ partner must be voluntary and cannot be a condition of
your employment.
I hereby rescind my previously led rejection of coverage. 
Sole Proprietor/Partner Signature Date
9.
Notary:
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
WC45 Rev 10/20
:
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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 sole proprietor/partner rejecting coverage. Incomplete forms may not be
processed and may be returned. Submit the forms to the insurance carrier or the Division of Workers’
Compensation per the below submission instructions.
The effective date of election is the day of receipt of said notice by Division. If a sole proprietor or partner
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 sole proprietorship, general
partnership (GP), limited partnership (LP), limited liability partnership (LLP), or a limited liability limited
partnership (LLLP). Sole proprietors wishing to reject coverage must have a trade name registered with the
Secretary of State pursuant to § 7-71-103, C.R.S. Partners wishing to reject coverage must be a partner in a
partnership that has filed with the Secretary of State a.) a certificate of limited partnership pursuant to §
7-62-201, C.R.S., b.) a partnership registration statement pursuant to § 7-60-144 or 7-64-1002, C.R.S., or c.)
a statement of trade name pursuant to § 7-71-103, C.R.S.
2.
True Name of Business: List the legal name of the business as filed with the Secretary of State.
3.
Registered Trade Name (if applicable): List the trade name of the business as filed with the Colorado
Secretary of State. Sole proprietorships and general partnerships MUST have a trade name registered with the
Colorado Secretary of State in order to be eligible to reject coverage.
4.
Mailing Address: List the complete business mailing address of the business including Street or P.O. Box,
Suite Number, City, State, and Zip Code.
5.
Email Address: List the business email address.
6.
Federal Employer Identification Number: List the 9-digit Federal Employer Identification Number
assigned to the business by the Internal Revenue Service.
7.
Business Phone: List the telephone number of the person signing Part A of the form.
8.
Date of Registration of Trade Name or Partnership: List the date the trade name or partnership was
registered with the Secretary of State. Must be registered in Colorado with an Effective status.
9.
Nature of work performed on construction sites: Briefly describe the type or nature of construction
work performed on construction sites.
10.
Sole Proprietor or Partner(s) rejecting coverage: List the full name and title for the sole proprietor or
partner in a partnership electing to reject workers’ compensation coverage. Please include first, middle, last, and
suffix if applicable. Attach separate sheet if more space is needed.
11.
Number of employees of the business other than the Sole Proprietor or Partners listed above: List
the number of employees other than the sole proprietor or partners listed under #10. Any person who is an
employee of the business who is not a sole proprietor or a partner in a partnership electing to reject coverage
must be insured for workers’ compensation.
12.
Submitted by: Type or legibly write the name and title of the individual submitting the form on behalf of
the business, and the date the form was completed.
WC45 Rev 10/20 Page 3 of 4
Part B
Sole Proprietor or Partner Questionnaire
To be completed by the sole proprietor or each partner electing to reject workers’ compensation insurance
coverage or rescinding a previous election.
1.
Sole Proprietor or Partner Name: List the full name of the sole proprietor or individual partner
completing Part B. Please include rst, middle, last, and sufx if applicable.
2. Title: List the title of the sole proprietor or individual partner completing Part B.
3. Business Phone: List the business telephone number of the sole proprietor or individual partner
completing Part B.
4A. If Sole Proprietor, Date Business Started: List the date the sole proprietor began business operations
in Colorado.
4B. If Partner, Date Became Partner: List the date the individual completing Part B became a partner in
the partnership.
5. True Name of Business: List the legal name of the business as filed with the Secretary of State.
6. Trade Name (if applicable): List the trade name of the business as filed with the Secretary of State.
7. Mailing Address: List the complete business mailing address of the business including Street or P.O. Box,
Suite Number, City, State, and Zip Code.
8. Mark ONE that applies: Check the appropriate box to indicate if the sole proprietor or individual partner
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: The signature of the sole proprietor or individual partner completing Part B must be notarized.
Mailing Instructions
File 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
WC45 Rev 10/20
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Rejection of Coverage by Partners and Sole Proprietors (Colorado DORA)

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Completed 27 January 2021

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