COLORADO DEPARTMENT OF LABOR AND EMPLOYMENTDIVISION OF WORKERS222 COMPENSATIONPART A 1. Type of Entity Sole Proprietorship þ General Partnership (GP) þ Limited Partnership (LP) þ Limited Liability Partnership (LLP) þ Limited Liability Limited Partnership (LLLP)2. True Name of Business 3. Registered Trade Name (if applicable) 4. Mailing Address Street or P.O. Box, Unit/Suite City State Zip þ þ þ 6. Business Phone 7. Date of Registration of Trade Name or Partnership 8. Nature of Work Performed on Construction Sites 9. Sole Proprietor or Partner(s) Rejecting Coverage (attach a separate sheet if necessary): Name Title (e.g. Sole Proprietor, General Partner, or Limited PartnerFirstMiddleLast10. Number of employees of the business other than the sole proprietor or partners listed above: 11. Submitted By: Name Title DateC.R.S. Section 10-1-128(6)(a) states: 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 NOTE: Sole Proprietors and General Partnerships MUST have a TRADE NAME registered with the Colorado Secretary of State. American LegalNet, Inc. www.FormsWorkFlow.com COLORADO DEPARTMENT OF LABOR AND EMPLOYMENTDIVISION OF WORKERS222 COMPENSATIONREJECTION OF COVERAGE BY PARTNERS AND SOLE PROPRIETORS PERFORMING CONSTRUCTION WORK ON CONSTRUCTION SITESPART B - Sole Proprietor or Partner QuestionnaireIMPORTANT: A separate Part B MUST be completed by every person listed in Part A.1. Sole Proprietor/Partner Name: þ þ þ 2. Title (e.g. Sole Proprietor, GeneralPartner, or Limited Partner) 3. Business Phone 4A. þ If Sole Proprietor: þ Date Business Started: þ 4B. þ If Partner: þ Date Became Partner: þ 5. True Name of Business 6. Trade Name (if applicable) 7. Mailing Address Street or P.O. Box, Unit/Suite City State Zip8. Mark ONE that Applies I hereby elect to reject workers222 compensation insurance coverage based on C.R.S. 247 8-41-404.and that if you are hurt on the job, C.R.S. 247 8-41-401(3) may limit your recovery to $15,000. The election to reject your employment. þ þ þ þ þ þ þ þ þ Sole Proprietor/Partner Signature þ Date9. Notary before me this day of þ , þ . Notary PublicIn and for þ þ þ Countyand þ þ þ State.My commission expires þ .C.R.S. Section 10-1-128(6)(a) states: 223It is unlawful to knowingly provide false, incomplete, or misleading facts or information to anof insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete ormisleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder orclaimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurancewithin the department of regulatory agencies.224 SEAL American LegalNet, Inc. www.FormsWorkFlow.com 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 þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ the below mailing 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 PART A1. Type of Entity: Check the appropriate box to indicate if the company is a sole proprietorship, generalpartnership (GP), limited partnership (LP), limited liability partnership (LLP), or a limited liability limitedpartnership (LLLP). Sole proprietors wishing to reject coverage must have a trade name registered with theSecretary of State pursuant to 247 7-71-103, C.R.S. Partners wishing to reject coverage must be a partner in a þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ 201, C.R.S., b.) a partnership registration statement pursuant to 247 7-60-144 or 7-64-1002, C.R.S., or c.) astatement of trade name pursuant to 247 7-71-103, C.R.S.2. True Name of Business: þ þ þ þ þ þ þ þ þ þ þ þ State.3. Registered Trade Name (if applicable): þ þ þ þ þ þ þ þ þ þ þ þ Secretary of State. Sole proprietorships and general partnerships MUST have a trade name registered with theColorado 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. þ þ þ þ þ þ þ assigned to the business by the Internal Revenue Service.6. Business Phone: List the telephone number of the person signing Part A of the form.7. Date of Registration of Trade Name or Partnership: List the date the trade name or partnership wasregistered with the Secretary of State.8. Nature of Work Performed on Construction Sites: þ þ þ þ þ þ þ þ work performed on construction sites.9. Sole Proprietor or Partner(s) Rejecting Coverage: List the full name and title for the sole proprietor þ 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.10. Number of employees of the business other than sole proprietor or partners listed above: List thenumber of employees other than the sole proprietor or partners listed under #9. Any person who is an employeeof the business who is not a sole proprietor or a partner in a partnership electing to reject coverage must beinsured for workers222 compensation.11. Submitted by: Type or legibly write the name and title of the individual submitting the form on behalf ofthe business, and the date the form was completed. American LegalNet, Inc. www.FormsWorkFlow.com PART B, SOLE PROPRIETOR OR PARTNER QUESTIONNAIRETo be completed by the sole proprietor or each partner electing to reject workers222 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 þ þ þ þ þ þ þ þ þ þ 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 partnercompleting Part B.4A. þ If Sole Proprietor, Date Business Started: List the date the sole proprietor began business operations in Colorado.4B. þ If Partner, Date Became Partner: List the date the individual completing Part B became a partner in the partnership.5. True Name of Business: þ þ þ þ þ þ þ þ þ þ þ þ þ State.6. Trade Name (if applicable): þ þ þ þ þ þ þ þ þ þ þ þ 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 þ þ þ þ þ þ þ þ þ þ þ þ þ þ coverage. The individual rejecting coverage or rescinding coverage must sign and date Part B. If the rescindingoption 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 address:Division of Workers222 CompensationCoverage Enforcement Unit633 17th St., Suite 400Denver, CO 80202-3626303.318.8700 American LegalNet, Inc. www.FormsWorkFlow.com