C.R.S. section 8-40-202(1)(a)(I)(B) provides an option to exclude from workers’ compensation insurance coverage uncompensated elected or appointed officials. You must promptly notify each official of your exercise of the option to exclude them. This form must be filed with the Division of Workers’ Compensation not less than forty-five (45) days before the start of the policy period for which the option is to be exercised. Attach governing body’s resolution.

 

By completing this form, you are certifying that the named uncompensated, elected or appointed public officials are designated to be excluded from worker’s compensation coverage for the upcoming policy year, pursuant to C.R.S. section 8-40-202(1)(a)(I)(B). You are also certifying that these officials have been notified of this exclusion.