DR 0811 (08/30/13) 
COLORADO DEPARTMENT OF REVENUE 
Denver, CO  80261-0005                                       *130811==19999*

                                Employees Election Regarding
                                Catastrophic Health Insurance

Employee's Last Name            First Name                   Middle Initial SSN

Employer's Name

Employer's Address                         City                                            State Zip

I hereby certify that I am an employee of the above listed employer who has offered catastrophic health insurance to 
employees under the provisions of §10-16-116, C.R.S. I further certify that I reside in the State of Colorado and that the 
above listed employer does not offer to provide me with any other form of health insurance.

I hereby elect to have this catastrophic health insurance withheld from my wages by my employer on a Colorado pretax basis.

This election will continue in effect until canceled by myself, by my employer or by the insurance carrier, or until I cease 
to be employed by this employer.
Signature                                                                                  Date (MM/DD/YY)