Division of Unemployment Insurance 
                                            Insurance Employer Services 
                                            P.O. Box 8789, Denver, CO 80201-8789 
 
  UNEMPLOYMENT INSURANCE PAYMENT ELECTION POLITICAL SUBDIVISION AND NONPROFIT EMPLOYERS 
 
A political subdivision of the state of Colorado or a 501(c)(3) nonprofit employer may elect to make reimbursement payments in lieu of 
premiums as provided in the Colorado Employment Security Act (CESA) 8-76-108 and 8-76-110(2)(d).  Nonprofit employers making 
this election must submit a security amount that is determined in accordance with CESA 8-76-110(4) and the Regulations Concerning 
Employment Security 8.1. 
 Legal Business Name                                                               Unemployment Insurance Account Number 
                                                                                    
 Trade or DBA Name (if applicable) 
  
 Mailing Address (include city, state, and zip code) 
  
 Telephone Number (Include area code) 

501(c)(3) Nonprofit 
A newly subject 501(c)(3) nonprofit employer may elect the reimbursement method of payment within 30 days of the date mailed on 
Form UITL-3, Notice of Employer Liability and Unemployment Insurance Account Number  .  A subject 501(c)(3) nonprofit employer 
may change its election for the following calendar year no later than December 1. 
 
Choose one: 
  ☐         Newly Subject Employer Election                             ☐ Subject Employer Election Change        
            The election will remain in force for not less than           This election will remain in force for not less than 
            the calendar year during which the organization was           two (2) calendar years beginning on January 1. 
            determined to be subject.                                      

 Choose one: 
  ☐         Make quarterly premium payments. 
            A 501(c)(3) nonprofit electing this option is required to pay premiums on the total chargeable wages for each 
            employee on a quarterly basis.  
  ☐         Make reimbursement payments in lieu of premiums.             
            A 501(c)(3) nonprofit electing this option is required to make payments to the Division in the full amount of all 
            regular benefits and one-half of the extended benefits paid that are attributable to service in the employ of the 
            501(c)(3) nonprofit.  A security is required and the amount will be calculated by the Division. 
 Date Election Begins  
 Estimated Annual Gross Wages (newly subject employers only) 
 
Political Subdivision of the State of Colorado (E.g., counties, municipalities, school and special districts) 
A newly subject political subdivision may elect the reimbursement method of payment within 30 days of the date mailed on Form UITL-
3, Notice of Employer Liability and Unemployment Insurance Account Number.  A subject political subdivision may change its election 
no later than March 1 of the year for which the election is to be effective.  The employer’s election may be changed on an annual basis. 
 
Choose one: 
  ☐         Make quarterly premium payments at the special group rate.             
            A political subdivision electing this option is required to pay premiums on the total subject wages for each 
            employee on a quarterly basis.  
  ☐         Make reimbursement payments in lieu of premiums.             
            A political subdivision electing this option is required to make payments to the Division in the full amount of all 
            regular and extended benefits paid that are attributable to service in the employ of the political subdivision.   
 Date Election Begins  
 Signature                                           Title                                                  Date 
                                                                                                             
 Department Use Only 
 Effective Date of Election                                             Date of Approval                                         
 Approved By                                                            Title                                                    
 
303-318-9100 (Denver-metro area) or 1-800-480-8299 (outside Denver-metro area) | www.coloradoui.gov 
UITR-13 (R 10/2018)