DR 0811 (08/30/13)
*130811==19999*
COLORADO DEPARTMENT OF REVENUE
Denver, CO 80261-0005
Employees Election Regarding
Catastrophic Health Insurance
Employee's Last Name
First Name
Middle Initial SSN
Employer's Name
Employer's Address
City
State
Zip
I hereby certify that I am an employee of the above listed employer who has offered catastrophic health insurance to
employees under the provisions of §10-16-116, C.R.S. I further certify that I reside in the State of Colorado and that the
above listed employer does not offer to provide me with any other form of health insurance.
I hereby elect to have this catastrophic health insurance withheld from my wages by my employer on a Colorado pretax basis.
This election will continue in effect until canceled by myself, by my employer or by the insurance carrier, or until I cease
to be employed by this employer.
Signature
Date
(MM/DD/YY)
DR 0811 (08/30/13)
*130811==19999*
COLORADO DEPARTMENT OF REVENUE
Denver, CO 80261-0005
Employees Election Regarding
Catastrophic Health Insurance
Employee's Last Name
First Name
Middle Initial SSN
Employer's Name
Employer's Address
City
State
Zip
I hereby certify that I am an employee of the above listed employer who has offered catastrophic health insurance to
employees under the provisions of §10-16-116, C.R.S. I further certify that I reside in the State of Colorado and that the
above listed employer does not offer to provide me with any other form of health insurance.
I hereby elect to have this catastrophic health insurance withheld from my wages by my employer on a Colorado pretax basis.
This election will continue in effect until canceled by myself, by my employer or by the insurance carrier, or until I cease
to be employed by this employer.
Signature
Date
(MM/DD/YY)
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