Rejection of Coverage - Colorado.gov 2026

1. Click ‘Get Form’ to open the Rejection of Coverage form in the editor.
2. Begin with Part A. Select the type of entity by clicking the appropriate checkbox for either Corporation or Limited Liability Company (LLC).
3. Enter the legal name of your corporation or LLC, followed by the complete mailing address including street, city, state, and zip code.
4. Provide a brief description of your business's nature and enter your Federal Employer Identification Number using numbers only.
5. Fill in the business phone number and date of incorporation. Ensure you include the state where your entity is incorporated.
6. List all corporate officers or LLC members rejecting coverage, including their names, titles, and ownership percentages.
7. Answer whether your company has workers' compensation insurance by checking 'Yes' or 'No'. If 'Yes', provide policy details.
8. Complete the certification section by typing in the name and signature of the Corporate Secretary or LLC Manager along with the date.
9. For each officer/member rejecting coverage, complete Part B separately. Include their details and ensure their signature is notarized.

Start filling out your Rejection of Coverage form online for free today!