Rejection Of Coverage By Corporate Officers Or Members Of Limited Liability Company With Instructions {WC43}

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENTDIVISION OF WORKERS222 COMPENSATION PART A1. Type of Entity þ Corporation þ Limited Liability Company (LLC)2. Name of Corporation or LLC 3. Mailing Address Street or P.O. Box, Unit/Suite City State Zip4. Nature of Business þ þ þ 6. Business Phone þ þ þ þ þ þ þ þ þ þ þ þ þ Coverage: Name Title(s) þ þ Ownership/Member InterestFirstMiddleLast10. Number of employees of the business other þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ Yes þ þ No þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ To þ I, þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ Name of Corporation or LLC þ þ þ þ þ þ þ þ þ þ þ 223It is unlawful to knowingly provide false, incomplete, or misleading facts or informationto an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may includewho knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purposeof defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable frominsurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.224 American LegalNet, Inc. www.FormsWorkFlow.com COLORADO DEPARTMENT OF LABOR AND EMPLOYMENTDIVISION OF WORKERS222 COMPENSATIONREJECTION OF COVERAGE BY CORPORATE OFFICERS OR MEMBERS OF A LIMITED LIABILITY COMPANY (LLC)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 þ þ þ þ þ þ þ þ þ þ þ 5. Business Phone þ þ 7. Duties performed for Corporation or LLC þ þ Applies: þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ Act and that if you are hurt on the job, C.R.S. 247 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 voluntary and cannot be a condition of your employment. þ þ þ þ þ þ þ þ þ þ þ þ þ 9. Notary: þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ be day of , . þ In and for þ þ þ Countyand þ þ þ State. þ þ . þ þ þ þ 223It is unlawful to knowingly provide false, incomplete, or misleading facts or informationto an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may includewho knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purposeof defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable frominsurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.224SEAL American LegalNet, Inc. www.FormsWorkFlow.com General Instructions: Complete all information. Type or legibly print. A separate questionnaire, Part B, þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ Part A1. Type of Entity: þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ 2. Name of Corporation or LLC: þ þ þ þ þ þ þ þ þ þ þ þ þ þ of State.3. Mailing Address: þ þ þ þ þ þ þ þ þ þ þ þ þ or P.O. Box, Suite Number, City, State, and Zip Code.4. Nature of Business: þ þ þ þ þ þ þ þ þ þ þ þ or LLC. þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ 6. Business Phone: þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ the form.7. Date of Incorporation or Organization: þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ LLC.8. State of Incorporation or Organization: þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ needed. List þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ insurance. If your þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ LLC. American LegalNet, Inc. www.FormsWorkFlow.com þ þ þ þ each þ þ þ þ þ þ þ þ þ þ þ þ þ þ 1. Name of Corporation or LLC: þ þ þ þ þ þ þ þ þ þ þ þ þ þ of State.2. Mailing Address: þ þ þ þ þ þ þ þ þ þ þ þ þ or P.O. Box, Suite Number, City, State, and Zip Code. þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ (if þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ 5. Business Phone: þ þ þ þ þ þ þ þ þ þ þ þ þ þ B. þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ position.7. Duties performed for Corporation or LLC: þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ B.8. Mark ONE that Applies: þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ 9. Notary: þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ be 10. Copy of form: þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ original forms.Mailing InstructionsInsured: If the corporation or LLC has þ þ þ þ þ þ þ þ þ Noninsured: If there is no þ þ þ þ þ þ þ þ þ þ þ þ þ þ address: þ þ þ þ þ 633 17th St., Suite 400 þ þ 303.318.8700 American LegalNet, Inc. www.FormsWorkFlow.com