Colorado > Workers Comp
Rejection Of Coverage By Partners And Sole Proprietors Performing Construction Work On Construction Sites WC45 - Colorado
| Rejection Of Coverage By Partners And Sole Proprietors Performing Construction Work On Construction Sites Form. This is a Colorado form and can be used in Workers Comp . |
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&2/25$'2 '(3$570(17 2) /$%25 $1' (03/2<0(17 ',9,6,21 2) :25.(56¶ &203(16$7,21 REJECTION OF COVERAGE BY PARTNERS AND SOLE PROPRIETORS PERFORMING CONSTRUCTION WORK ON CONSTRUCTION SITES PART A 7\SH RI (QWLW\ 6ROH 3URSULHWRUVKLS *HQHUDO 3DUWQHUVKLS *3 NOTE: Sole Proprietors and General Partnerships MUST have a TRADE NAME registered with the Colorado Secretary of State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irst Middle Last Suffix (Jr., Sr., III) 1XPEHU RI HPSOR\HHV RI WKH EXVLQHVV other WKDQ WKH VROH SURSULHWRU RU SDUWQHUV OLVWHG DERYH 6XEPLWWHG E\ 1DPH 7LWOH 'DWH &56 6HFWLRQ D VWDWHV "It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies." WC 045 05/01/08 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com &2/25$'2 '(3$570(17 2) /$%25 $1' (03/2<0(17 ',9,6,21 2) :25.(56¶ &203(16$7,21 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. 6ROH 3URSULHWRU3DUWQHU 1DPH 7LWOH HJ 6ROH 3URSULHWRU *HQHUDO 3DUWQHU RU /LPLWHG 3DUWQHU $ ,I 6ROH 3URSULHWRU % ,I 3DUWQHU 7UXH 1DPH RI %XVLQHVV 7UDGH 1DPH LI DSSOLFDEOH 0DLOLQJ $GGUHVV 6WUHHW RU 32 %R[ 8QLW6XLWH &LW\ 6 WDWH =LS )LUVW 0LGGOH /DVW %XVLQHVV 3KRQH 6XIIL[ -U 6U ,,, 'DWH %XVLQHVV 6WDUWHG 'DWH %HFDPH 3DUWQHU 0DUN 21( WKDW $SSOLHV , KHUHE\ HOHFW WR UHMHFW ZRUNHUV¶ FRPSHQVDWLRQ LQVXUDQFH FRYHUDJH EDVHG RQ &56 By signing this form, you are acknowledging your rejection of all benefits under the Workers' Compensation Act. The election to reject workers' compensation insurance as a sole proprietor/partner must be voluntary and cannot be a condition of your employment. , KHUHE\ UHVFLQG P\ SUHYLRXVO\ ILOHG UHMHFWLRQ RI FRYHUDJH 6ROH 3URSULHWRU3DUWQHU 6LJQDWXUH 'DWH 1RWDU\ 6XEVFULEHG DQG VZRUQ WR EH EHIRUH WKLV BBBBBB GD\ RI BBBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 1RWDU\ 3XEOLF 6($/ ,Q DQG IRU BBBBBBBBBBBBBBBBBBBBBBBBB &RXQW\ DQG BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB6WDWH 0\ FRPPLVVLRQ H[SLUHV BBBBBBBBBBBBBBBBBBBB &56 6HFWLRQ D VWDWHV "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." WC 045 05/01/08 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS/DEFINITIONS General Instructions: &RPSOHWH DOO LQIRUP DWLRQ 7\ SH RU OHJLEO\ SULQW A separate questionnaire, Part B, must be completed and attached for each sole proprietor/partner rejecting coverage. ,QFRPSOHWH IRUPV PD\ QRW EH SURFHVVHG DQG PD\ EH UHWXUQHG 0DLO WKH IRUP V E\ FHUWLILHG P DLO WR WK H 'LYLVLRQ RI :RUNHUV¶ &RP SHQVDWLRQ SHU WKH EHORZ P DLOLQJ LQVWUXFWLRQV 7KH HIIHFWLYH GDWH RI HOHFWLRQ LV WKH GD\ RI UHFHLSW RI VDLG QRWLFH E\ 'LYLVLRQ ,I D VROH SURSULHWRU RU SDUWQHU FKDQJHV KLVKHU HOHFWLRQ D UHYLVHG TXHVWLRQQDLUH PXVW EH ILOHG Part A 1. Type of Entity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rue Name of Business: /LVW WKH OHJDO QDPH RI WKH EXVLQHVV DV ILOHG ZLWK WKH 6HFUHWDU\ RI 6WDWH Registered Trade Name (if applicable): /LVW WKH WUDGH QDPH RI WKH EXVLQHVV DV ILOHG ZLWK WKH &RORUDGR 6HFUHWDU\RI 6WDWH 6ROH SURSULHWRUVKLSV DQG JHQHUD SDUWQHUVKLSV 0867 KDYH D WUDGH QDP UHJLVWHUHG ZLWKWKH &RORUDGR 6HFUHWDU\ O H RI 6WDWH LQ RUGHU WR EH HOLJLEOH WR UHMHFW FRYHUDJH Mailing Address: /LVW WKH FRP SOHWH EXVLQHVV PDLOLQJ DGGUHVV RI WKH EXVLQHVV LQFOXGLQJ 6WUHHW RU 32 %R[ 6XLWH 1XPEHU &LW\ 6WDWH DQG =LS &RGH Federal Employer Identification Number: /LVW WKH GLJLW )HGHUDO (PSOR\HU ,GHQWLILFDWLRQ 1XPEHU DVVLJQHG WR WKH EXVLQHVV E\ WKH ,QWHUQDO 5HYHQXH 6HUYLFH Business Phone: /LVW WKH WHOHSKRQH QXPEHU RI WKH SHUVRQ VLJQLQJ 3DUW $ RI WKH IRUP Date of Registration of Trade Name or Partnership: /LVW WKH GDWH WKH WUDGH QDP RU SDUWQHUVKLS ZDV UHJLVWHUHG ZLWK H WKH 6HFUHWDU\ RI 6WDWH Nature of Work Performed on Construction Sites: %ULHIO\ GHVFULEH WKH W\ SH RU QDWXUH RI FRQVWUXFWLRQ ZRUN SHUIRUPHG RQ FRQVWUXFWLRQ VLWHV Sole Proprietor or Partner(s) Rejecting Coverage: /LVW WKH IXOO QDP DQG WLWOH IRU WKH VROH SURSUHWRU RU SDUWQHU LQ D H L SDUWQHUVKLS HOHFWLQJ WR UHMHFW ZRUNHUV¶ FRP SHQVDWLRQ FRYH UDJH 3OHDVH LQFOXGH ILUVW P LGGOH ODVW DQG VXIIL[ LI DSSOLFDEOH $WWDFK VHSDUDWH VKHHW LI PR
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