Colorado > Workers Comp
Rejection Of Coverage By Corporate Officers Or Members Of Limited Liability Company With Instructions WC43 - Colorado
| Rejection Of Coverage By Corporate Officers Or Members Of Limited Liability Company With Instructions Form. This is a Colorado form and can be used in Workers Comp . |
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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. Nature of Business 5. Federal Employer Identification Number 7. Date of Incorporation or Organization 6. Business Phone 8. State of Incorporation or Organization 9. Corporate Officers or LLC Members Rejecting Coverage: Name(s) First Middle Last Suffix (Jr., Sr., III) Title(s) Percent of Ownership/ Membership Interest 10. Number of employees of the corporation or LLC other than officers or members listed above 11A. Does your company have workers' compensation insurance? Yes ______ No ______ 11B. If you answered "Yes" to Question 11A, please include your workers' compensation policy information below and submit this completed form directly to your carrier. If you answered "No" to Question 11A, please submit this completed form directly to the Colorado Division of Workers' Compensation. a. Insurer Name c. Effective Dates 12. Certification: From To b. Policy Number I, _____________________________________________, in my capacity as Corporate Secretary or LLC Manager Name of Corporate Secretary or LLC Manager of ________________________________, 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 02/12 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 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 3. Officer or Member Name First 4. Corporate Officer Title 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 benefits under the Workers' Compensation Act. 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 officer/LLC member must be voluntary and cannot be a condition of your employment. Middle Last 5. Business Phone Suffix (Jr., Sr., III) I hereby rescind my previously filed rejection of coverage. Corporate Officer/LLC Member Signature Date 9. Notary Subscribed and sworn to be before this ______ day of _________________________,______________ ________________________________________ Notary Public SEAL 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, 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 02/12 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 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. 2. 3. 4. 5. 6. 7. 8. 9. Type of Entity: Check the appropriate box to indicate if the company is a corporation or a limited liability company (LLC). Name of Corporation or LLC: List the legal name of the corporation or LLC as filed with the Secretary of State. 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. Nature of Business: Briefly describe the type and nature of business conducted by the corporation or LLC. Federal Employer Identification Number: List the 9-digit Federal Employer Identification Number assigned to the corporation or LLC by the Internal Revenue Service. Business Phone: List the telephone number of the Corporate Secretary or LLC Manager signing Part A of the form. 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. State of Incorporation or Organization: List the state where the corporation is incorporated or where the LLC filed its Articles of Organi
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