HomeMy WebLinkAbout20131056.tiffRESOLUTION
RE: APPROVE EXCLUSION OF VOLUNTEER APPOINTED MEMBERS OF WELD
COUNTY ADVISORY BOARDS FROM WORKER'S COMPENSATION COVERAGE,
PURSUANT TO SECTION 8-40-202, C.R.S.
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, Section 8-40-202(1)(a)(l)(B), C.R.S., authorizes the Board of County
Commissioners to exclude any appointed advisory board members, who receive no
compensation, from Worker's Compensation coverage, and
WHEREAS, the Board of County Commissioners of Weld County, Colorado, believes
that it is in the best interests of the citizens of Weld County, Colorado that such appointed
advisory board members be excluded from Worker's Compensation coverage.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of
Weld County, Colorado, that all advisory board members who are not otherwise employed by
Weld County shall be excluded from Worker's Compensation coverage, and the Department of
Human Resources is authorized to file, periodically and as needed or requested by the
Colorado Department of Labor and Employment, an appropriate form or statement in order to
accomplish the purpose of this Resolution.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 1st day of May A.D., 2013.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY. CQLORADO
Weld County Clerk to the
BY:
Deputy Clerk to the Boa
APP' ? ' P. AS TO
III/
ounty A torney
Date of signature: 54
Sean P. Conway
Mike Freeman
EXCUSED
Barbara Kirkmeyer
(B6b,
cRzfoLk, sin
2013-1056
PE0031
Department of Labor and Employment
Division of Workers' Compensation
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)(l)(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
2013-1056
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