Form WC44 "Exclusion of Uncompensated Public Officials" - Colorado

What Is Form WC44?

This is a legal form that was released by the Colorado Department of Labor and Employment - a government authority operating within Colorado. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2012;
  • The latest edition provided by the Colorado Department of Labor and Employment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WC44 by clicking the link below or browse more documents and templates provided by the Colorado Department of Labor and Employment.

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Download Form WC44 "Exclusion of Uncompensated Public Officials" - Colorado

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Instructions for Completing the
Go to Form
Exclusion of Uncompensated
Officials
Please read all pages
This form is “fillable.” That means you can type the information onto
the form from your computer and print the form. You will not be able
to save the form onto your computer’s hard drive.
When you open the form, click in the “Name of Agency” box (field),
and use the tab key to navigate to the next field. Do not use the Enter
key; pressing the Enter key will only page down. Each field has been
limited. This means that you cannot continue to type information into
a field if it doesn’t fit into the space provided.
Use numbers only to fill in the fields for Official’s Social Security # and
Business Phone #. Do not use dashes or parentheses; when you tab
out of the field, it will fill in automatically.
To clear or delete all the information you have typed onto the form,
click on the red
“Clear Entire
Form” button. o change the information
in a single field, use the backspace or delete key.
1
Instructions for Completing the
Go to Form
Exclusion of Uncompensated
Officials
Please read all pages
This form is “fillable.” That means you can type the information onto
the form from your computer and print the form. You will not be able
to save the form onto your computer’s hard drive.
When you open the form, click in the “Name of Agency” box (field),
and use the tab key to navigate to the next field. Do not use the Enter
key; pressing the Enter key will only page down. Each field has been
limited. This means that you cannot continue to type information into
a field if it doesn’t fit into the space provided.
Use numbers only to fill in the fields for Official’s Social Security # and
Business Phone #. Do not use dashes or parentheses; when you tab
out of the field, it will fill in automatically.
To clear or delete all the information you have typed onto the form,
click on the red
“Clear Entire
Form” button. o change the information
in a single field, use the backspace or delete key.
1
“Clear Entire
Form” button
Clears all information at once
2
Department of Labor and Employment
Division of Workers’ Compensation
Back to Instructions
Clear Entire Form
633 17th St., Suite 400, Denver, CO 80202-3626
Telephone: 303.318.8640 Fax: 303.318.8739
EXCLUSION OF UNCOMPENSATED PUBLIC OFFICIALS
Name of Agency: __________________________________________________________________________________
Federal Employer Identification # (FEIN): __________________________Business Phone #: (______)______________
Mailing Address: __________________________________________________________________________________
Street or P.O. Box / Suite #
________________________________________________________________________________________________
City
State
Zip
If Self-Insured Employer, enter the Permit Number: _______________________________________________________
If not Self-Insured, enter the workers’ compensation insurance carrier name and policy number:
________________________________________________________________________________________________
Insurance Carrier Name
Policy Number
Upcoming Policy Period:
From: _________________
To: ________________________
Month / Year
Month / Year
List the Governing Body for the Agency, Category of uncompensated officials (i.e. board, commission, etc.) or any
combination of categories of such officials that you are opting to exclude from coverage for the upcoming policy year
and Names of Officials (Attach additional pages if needed):
Name of Governing Body: __________________________________________________________________________
Category
Name of Official
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
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 signing this form, you are certifying that the above-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.
Signature: ______________________________________________________________________________________
Print Name: _____________________________________________________________________________________
Date: __________________ Title: ___________________________________________________________________
Submit this form with the Governing Body’s Resolution to: Division of Workers’ Compensation, Coverage
Enforcement Unit, 633 17th St., Suite 400, Denver, CO 80202-3626. If insured, please make a copy of this
completed form and send it to your insurance carrier. If you have any questions, contact the Division of Workers’
Compensation Customer Service Unit at 303.318.8700.
C.R.S. section 10-1-128(6)(a) states: “ It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance,
and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or
information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a
settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of
Regulatory Agencies.”
WC44 Rev 02/12
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