ACORD 171 CO (2006/01)

Section Name
Field Name
Field and/or Section Description
ACORD 171 CO (2006/01)
Rejection of Coverage By
Corporate Officers or Members of
a Limited Liability Company
Use this form to notify the Colorado Division of Workers Compensation, Employer
Compliance Unit, that an employee who is an officer of a corporation or a member of a
limited liability company elects to be excluded from workers compensation insurance
ACORD 171 CO (2006/01)
1 of 1