Cripple Creek, CO · Teller County
Rejection of Workers’ Compensation Coverage
This Colorado workers’ compensation form lets construction-work sole proprietors and partners elect to reject coverage or rescind a prior rejection, with a separate questionnaire for each person.
- licensed online notary
- ~15 min average
- Notarized PDF emailed
What you’ll need
- Government-issued photo ID
- Webcam-enabled device (laptop or phone)
- This form, ready to upload as a PDF
What this form is
The form gathers business and worker details in Part A, then requires each listed sole proprietor or partner to complete a separate Part B questionnaire. Each person can elect to reject workers’ compensation coverage or rescind a previously filed rejection. The form states that rejection must be voluntary and describes possible limits on recovery if the signer is hurt on the job.
Who needs it
Sole proprietors and partners performing construction work on construction sites use this form to reject workers’ compensation coverage or rescind a previous rejection.
Why it needs a notary
Part B contains a subscribed-and-sworn jurat; the sole proprietor or partner completing that questionnaire signs before the notary.
How to get this notarized
- 1
Download The Form
Download the Rejection of Coverage by Partners and Sole Proprietors form.
- 2
Complete The Business Details
Fill out Part A with the business information and identify each sole proprietor or partner rejecting coverage.
- 3
Complete A Questionnaire
Have each person listed in Part A complete a separate Part B and mark the applicable election.
- 4
Book An Online Notary
Schedule a remote notarization for the Part B signer’s subscribed-and-sworn jurat.
- 5
Sign On Video
Sign Part B during the online notary session and complete the jurat.
- 6
Submit The Form
Submit the completed form to the city or other recipient identified by the office requesting it.
Preview the form
The blank PDF straight from Cripple Creek. Look it over, then upload your filled copy to start the notary session.
You’ll need ID and a webcam.
A licensed online notary will join you on video, verify your government-issued ID, witness your signature, and apply their seal. You’ll receive the notarized PDF by email when the session ends.
Frequently asked questions
- How do I complete the rejection of coverage form?
- Complete Part A with business information, then have each listed sole proprietor or partner complete a separate Part B. The signer makes an election, signs before a notary, and submits the completed form to the appropriate recipient.
- Do I need to complete a separate Part B?
- Yes. The form says a separate Part B must be completed by every person listed in Part A.
- Can I sign Part B with an online notary?
- Colorado authorizes its notaries to perform remote online notarizations under C.R.S. §24-21-514.5. A commissioned online notary can notarize the jurat by video; confirm with the city or town if unsure.
- What does signing the rejection election acknowledge?
- The form says the signer acknowledges rejecting all benefits under the Workers’ Compensation Act and warns that recovery after an on-the-job injury may be limited to $15,000.