Part B, Corporate Officer or LLC Member Questionnaire To be completed by Officer or Member electing to reject compensation insurance coverage or each workers’ rescinding a previous election. 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. List the name of the individual corporate officer or LLC member Officer or Member Name: completing Part B. List the full name of the person rejecting coverage. Please include first, middle, last, and suffix (if applicable). List the title of the individual corporate officer completing Part B. If an Corporate Officer Title: LLC member is completing Part B, leave blank. Business Phone: List the business telephone number of the individual corporate officer or LLC member completing Part B. Date Officer/Member Elected: List the date the individual corporate officer or LLC member completing Part B was elected to the position. 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. Mark ONE that Applies: Check the appropriate box to indicate if the individual corporate officer or LLC member completing Part B is rejecting compensation coverage or rescinding a previously worker’s 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. Notary: If this form is being filed with the Division of Compensation, the signature of the Workers’ 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. 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 insurance carrier, file this form by workers’ compensation certified mail directly with your insurance carrier. file this form by certified mail with the Noninsured: If there is no insurance carrier, workers’ compensation Division of Compensation at the following address: Workers’ Division of Compensation Workers’ Coverage Enforcement Unit 633 17th St., Suite 400 Denver, CO 80202-3626 303.318.8700
Part B, Corporate Officer or LLC Member Questionnaire To be completed by each Officer or Member electing to reject workers’ compensation insurance coverage or rescinding a previous election. 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. 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). Corporate Officer Title: List the title of the individual corporate officer completing Part B. If an LLC member is completing Part B, leave blank. Business Phone: List the business telephone number of the individual corporate officer or LLC member completing Part B. Date Officer/Member Elected: List the date the individual corporate officer or LLC member completing Part B was elected to the position. 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. Mark ONE that Applies: 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. 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. 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, file this form by certified mail directly with your insurance carrier. Noninsured: If there is no workers’ compensation insurance carrier, file this form by certified 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
WC043_Rejection_Of_Coverage.docx