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         Colorado Department of Labor and Employment, Unemployment Insurance Employer Services, P.O. Box 8789, Denver, CO 80201-8789 
                                      303-318-9100 (Denver-metro area) or 1-800-480-8299 (outside Denver-metro area) 
                                                                  www.coloradoui.gov 
                                                                             
                                                                                          Department Use Only 

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                            APPLICATION  FOR  UNEMPLOYMENT  INSURANCE  ACCOUNT 
                                      AND  DETERMINATION  OF  EMPLOYER  LIABILITY 
Complete and mail this application to the address at the top of this page to register your business with us for unemployment insurance (UI) purposes.  We will 
review your application and determine whether you must provide UI coverage for your employees.       All items must be completed.  If an item is not applicable 
(NA) to you or your business, enter “NA.”  You can provide additional information at the bottom of page 4 of this application or attach additional sheets of paper. 
1. First Date of Payroll in Colorado (Do not provide a future date.  If the first date of payroll in Colorado has not occurred, do not complete this application.) 
 
2. Provide the reason for filing this application. 
      Original application         Reinstatement of existing account        Account  Number                                                                 
      Change of ownership (enclose a copy of the sales agreement and a list of the board of directors for the new business and all acquired businesses) 
3. Type of Organization (check only one box) 
      Individual/Sole Proprietor             Joint Venture 
      General Partnership                    Limited Partnership 
      Corporation                            Limited Liability Partnership 
      “S” Corporation                        Limited Liability Limited Partnership 
      Association                            Limited Liability Company (reported as corporation on Internal Revenue Service Form 8832) 
      Trust                                  Limited Liability Company (reported as sole proprietor or partnership on Internal Revenue Service Form 8832) 
      Estate                                 Stock Sale (only complete page 1 of this application and sign on page 4) 
      Government                             Other ________________________________________________ 
      Religious Organization 
      Nonprofit as defined by section 501(c)(3) of the Internal Revenue Code (enclose a copy of your exemption letter from the Internal Revenue Service) 
      Other Nonprofit                                                                                       
4. Basic Information—Provide the requested employer, address, and contact information. 
    
Legal Business Name (Enter the actual name of the business registered with the Secretary of State, including suffixes such as Inc or LLC, if applicable) 
 
Trade Name/Doing-Business-As Name (if applicable)                                                    Federal Employer Identification Number (required) 
                                                                                                      
Street Address of Principal Place of Business in Colorado (provide a residence address only if it is the only Colorado address; include city, state, and ZIP code) 
 
Telephone Number                 Cellular Telephone Number           E-mail Address                               Web-site Address 
                                                                                                                   
Mailing Address if Different From Above (include city, state,  and ZIP code, and in-care-of name, if applicable)                Telephone Number 
                                                                                                                                 
Legal Name of Owner, Partner, or Corporate Officer     Title                                       Social Security Number       Telephone Number 
                                                                                                                                 
Complete Address of Owner, Partner, or Corporate Officer (Residence or P.O. Box, include city, state, and ZIP code)             Cellular Telephone Number 
                                                                                                                                 
Legal Name of Owner, Partner, or Corporate Officer     Title                                       Social Security Number       Telephone Number 
                                                                                                                                 
Complete Address of Owner, Partner, or Corporate Officer (Residence or P.O. Box, include city, state, and ZIP code)             Cellular Telephone Number 
                                                                                                                                 
Attach additional sheets of paper if there are additional owners, partners, or corporate officers. 
 
Bank Name and Address (provide complete address; include city, state, and ZIP code) 
 
Payroll-Records Location (provide complete address; include city, state, and ZIP code)                                 Payroll-Records Telephone Number 
                                                                                                                        
Office Use Only             Coding “Q” Number         Coding Date                          Input “Q” Number ________________ 
Account Type                 NAICS                    Organization Code                    Liability Code               Liability Date ________________ 
Qualifying Date                        Status Code _______________ UITR-1  ____________________          

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5. Has this business paid wages or paid other remuneration in lieu of wages such as dividends (“S” corporation only), bonuses, draws, or disbursements?
Yes No
NOTE: Wages include payments made to corporate officers performing any services in Colorado.
If Yes, provide the federal employer identification number (FEIN) if different than the FEIN provided in Item 4or the UI account number if different
than the account number provided in Item 2if applicable. ___________________________________________________________
6. Has this business paid any individual who is considered to be a contractor or subcontractor? Yes No
7. Has the business issued or does it intend to issue IRS Form 1099-MISC to any individual. Yes No
If Yes to Item 6or ,7describe the type of work performed_____________________
8. Is this business an employee-leasing company (i.e., does it lease employees to other businesses or management companies)? Yes No
9. Are the employees of this business hired through an employee-leasing company or management company? Yes No
If Yes: Provide the name of the employee-leasing or management company
Provide the FEIN and/or UI account number_______________________________________________________________
10. Is this business an individual/sole proprietor? Yes No
If Yes, are there any employees other than the individual, his or her spouse, or his or her children under the age of 21? Yes No
11. Is this business a partnership or limited liability organization? Yes No
If Yes, are there any employees other than the partners or members of the limited liability organization? Yes No
12. Select the item that best describes the business’s activity in Colorado (check only one box) and provide specific detail below. For additional information
regarding these industry descriptions, call Labor Market Information (LMI) at 303-318-8850 or contact LMI in writing at 633 17 thStreet, Suite 600, Denver,
CO 80202. Additional information is available online at lmigateway.coworkforce.com/lmigateway.
Agricultural (list crops, animals, and/or services provided) Construction—General Contractor
Mining (list product being mined and/or services performed) Residential
Utilities (list type and services performed) Single Family
Transportation, Communication, or Public Utilities (list type) Multiple Family
Retail Trade (list type of product sold and to whom) Commercial
Wholesale Trade (list type of product sold and to whom) Industrial/Warehouse
Service (list type and explain in detail) Other Commercial
Finance, Insurance, or Real Estate (list type and explain in detail) Speculative Builder/For Sale by Owner
Manufacturing and Assembly (list materials used and products rendered) Subcontractor (explain in detail)
Government (list type of agency) Heavy Construction
Household/Domestic Highway and Steel Construction
Other Bridge, Tunnel, and/or Elevated Highway
Water, Sewer, Pipeline, and/or Communication
Other Heavy Construction
Provide specific detail regarding the business’s activity in Colorado. If more than one service is provided, indicate which is predominant.

NOTE: If the business’s entire activity is seasonal or if it has seasonal occupations, a request for seasonal designation can be made by completing and
returning Form UITL-5, Request for Seasonal Determination. To obtain this form, go to www.colorado.gov/cdle/ui, click on Forms and Publications,
and then click on Employer Forms . If you have any questions regarding seasonal status, call us at one of the telephone numbers at the top of the initial
page of this application.
13. Worksite Information—Provide the following information for each physical location in Colorado. Do not provide P.O. boxes, payroll, or accountant
addresses. If an employee works from his or her home, you must provide the employee’s residence address. Attach additional sheets of paper for more than
one physical location in Colorado.
Complete Physical Street Address of Worksite (include city, state, and ZIP code)

Worksite Telephone Number Worksite Contact Person Average Number of Employees in a Typical Month

14. Business Acquisition—For purposes of this application, an acquisition is defined as the purchase or transfer of any or all of the assets and/or employees of
a previously established business. If this business entity was acquired, in accordance with CESA 8-76-104, we must make a determination regarding the purpose
of the business acquisition. If you have any questions regarding the acquisition of a business, call us at one of the telephone numbers at the top of the initial
page of this application. Enclose a copy of the sales agreement and a list of the board of directors for the new business and all acquired businesses.
Is the business entity completing this application as a result of a business acquisition? Yes No If No, skip to Item 17.
If Yes: Provide the date of acquisition
Check one of the boxes below to indicate the type of acquisition and complete Items 15 and 16.
Total Business Acquisition or Employee Transfer—This business acquired all of the organization, trade, or business or substantially
all of the assets of at least one employer or utilizes the services of 90 percent or more of the total number of employees from another
employer.
NOTE: This can include a reorganization of a current business.
Partial Business Acquisition or Employee Transfer—This business acquired some of the organization, trade, or business or assets of
at least one employer or utilizes the services of less than 90 percent of the total number of employees from another employer.
NOTE: This can include a reorganization of a current business.
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 15.  Did the business entity acquire or hire any workers from the prior business who are now employed with the new business?             Yes        No 
         If Yes:  How many employees were acquired?                                 
                   How many employees did the prior business have during its last four pay periods?       Last Pay Period                   
                   Second-to-Last Pay Period                  Third-to-Last Pay Period                         Fourth-to-Last Pay Period_____________  
 16.  Provide the following information regarding the prior employer. 
 Prior Legal Business Name                                                                                  Prior FEIN or UI Account Number 
                                                                                                             
 Name of Prior Owner                                                                                        Current Telephone Number of Prior Owner 
                                                                                                             
 Complete Current Address of Prior Owner (include city, state, and ZIP code) 
  
 17.  In accordance with the Colorado Employment Security Act (CESA), employers are required to provide UI coverage if one of the following conditions 
 are met.  Employers can meet these conditions through the employment of full-time, part-time, and temporary workers (including temporary agricultural 
 workers with an H-2A visa). 
  NOTE:  Calendar quarters are defined as January–March, April–June, July–September, and October–December. 
 Check the appropriate box and provide the corresponding information that is requested. 
 Commercial,Industrial,or Professional Organization   (as defined in CESA 8-70-113)   
     Paid one or more workers a total of $1,500 in gross wages during any calendar quarter in the current or preceding calendar year 
         Date on which you paid $1,500 in gross wages during a calendar quarter to meet this requirement                                   
     Employed one or more workers for some portion of a day in 20 different calendar weeks during the current or preceding calendar year (all 20 calendar 
         weeks must occur within the same calendar year)   
         NOTE:  The services do not have to be performed in consecutive weeks or by the same employee. 
         Date on which you first employed a worker for some portion of a day to meet this requirement                                    
         Date on which you employed a worker for some portion of a day in the 20 thcalendar week to meet this requirement ______________________ 
 Agricultural Employer (as defined in CESA 8-70-120) 
     Paid one or more agricultural workers a total of $20,000 in gross wages during any calendar quarter in the current or preceding calendar year 
         Date on which you paid $20,000 in gross wages during a calendar quarter to meet this requirement                                  
     Employed ten or more workers for some portion of a day in 20 different calendar weeks during the current or preceding calendar year (all 20 calendar  
         weeks must occur within the same calendar year)   
         NOTE:  The services do not have to be performed in consecutive weeks or by the same ten employees. 
         Date on which you first employed ten workers for some portion of a day to meet this requirement                                  
         Date on which you employed ten workers for some portion of a day in the 20 thcalendar week to meet this requirement _____________________ 
 HouseholdDomestic-Services/ Employer   (as defined in CESA 8-70-121) 
     Paid one or more workers performing domestic services in a private home, local college club, or local chapter of a fraternity or sorority a total of 
         $1,000 in gross wages during any calendar quarter in the current or preceding calendar year 
         Date on which you paid one or more workers $1,000 in gross wages during a calendar quarter to meet this requirement _____________________  
 Nonprofit Organization, Including Political Subdivision (exempt under section 501(c)(3) of the Internal Revenue Code and as defined in CESA 8-70-118) 
     Political Subdivision/Government 
     Had four or more workers employed anywhere in the U.S. in any calendar quarter in the current calendar year or preceding calendar year   
         NOTE:  The services do not have to be performed in consecutive weeks or by the same four employees. 
         Date on which you first employed at least one worker in Colorado                                      
         Date on which you first employed four workers anywhere in the U.S. to meet this requirement                                  
         Date on which you employed four workers anywhere in the U.S. in the 20 thcalendar week to meet this requirement                             
         Type of services provided ____________________________________________________________________________ 
 18.  Has the owner, partner, or corporate officer of this business entity owned or operated any business in Colorado or does the owner, partner, or corporate 
   officer currently own or operate any other business in Colorado?      Yes              No 
         If Yes, provide the information requested below for each business regardless of whether it is still in operation or related to this business entity.  In 
         addition, provide the requested information for all affiliated businesses.  Attach additional sheets of paper if necessary. 
 Legal Business Name                                                          UI Account Number                    FEIN 
                                                                                                                    
 Legal Business Name                                                          UI Account Number                    FEIN 
                                                                                                                    
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19. Will the business entity file a consolidated federal tax return, including Internal Revenue Service Form 851, with any other business or entity?
Yes No
If Yes, provide the information requested below for each business or entity included in the consolidated tax return. Attach additional sheets of paper
if necessary.
Legal Business Name UI Account Number FEIN

Legal Business Name UI Account Number FEIN

20. Is this business entity the result of a reorganization of a previously existing business entity or entities? Yes No
If Yes, provide the information requested below for all business entities. Attach additional sheets of paper if necessary.
NOTE: Attach a copy of your reorganization plan. Provide the names of all corporate officers for all entities, a statement explaining the reason for the
reorganization, and any cost-benefit analysis that was completed in relation to the reorganization.
Legal Business Name UI Account Number FEIN

Legal Business Name UI Account Number FEIN

21. Was this business entity purchased as a franchise from a corporation or franchisor? Yes No
Was this business entity purchased as a franchise from a corporation or franchisee? Yes No
22. Please provide additional information or comments in the space provided below. If you are providing information relative to a question above, please note
the question number.
Information/Comments

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The classification of a worker as an independent contractor or exempt employee has significant implications       .  Section 8-72-
114, C.R.S., prohibits misclassification of employees.  
 
  a. An employer has improperly classified an individual when an employer-employee relationship exists, as determined in 
  subsection (2)(f) of this section and Section 8-70-115, C.R.S., but the employer has not classified the individual as an employee. 
  b. An "employer-employee" relationship shall be presumed to exist when work is performed by an individual for remuneration 
  paid by an employer, unless to the satisfaction of the Department the employer demonstrates that the individual is an exempt 
  person or independent contractor. 
  c. A person shall not knowingly incorporate or form, or assist in the incorporation or formation of, a corporation, partnership, 
  limited liability corporation, or other entity, or pay or collect a fee for use of a foreign or domestic corporation, partnership, 
  limited liability corporation, or other entity for the purpose of facilitating, or evading detection of, a violation of this section. 
  d. A person shall not knowingly conspire with, aid and abet, assist, advise, or facilitate an employer with the intent of violating 
  the provisions of this chapter. 
 
Further, in the event that any employer is found to violate Section 8-72-114, C.R.S, the penalties for such violation are set forth in 
subsection (3)(e), which states in pertinent part that: 
  (III) Upon a finding that the employer, with willful disregard of the law, misclassified employees, the director may: 
     (A) Impose a fine of up to $5,000 per misclassified employee for the first misclassification with willful disregard, and for a 
     second or subsequent misclassification with willful disregard, a fine of up to $25,000 per misclassified employee; and 
     (B) Upon a second or subsequent misclassification with willful disregard, issue an order prohibiting the employer from 
     contracting with, or receiving any funds for the performance of contracts from the state for up to two years after the date of 
     the director's order.  Upon the issuance of such order, the director shall notify state departments and agencies as necessary 
     to ensure enforcement of the order. 
 
I, _______________________________________________________________, (company officer) have read and understood the 
prohibitions and penalties set forth above.  
 
 I certify under penalty of perjury that the above information is true, accurate, and complete to the best of my knowledge.  I 
 understand that there are severe penalties for providing false statements and willfully misrepresenting information in order to 
 reduce UI rates. 
 Name of Company Officer (please print)                            Title 
                                                                    
 Telephone Number                       Alternate Telephone Number             E-mail Address 
                                                                                
 Signature of Company Officer                                                  Date 
                                                                                
NOTE: The completion of this application is for UI purposes only.  If you need to register your business in Colorado for other purposes such as establishing 
wage withholding, applying for a state sales tax license, or registering a trade name, complete Form CR 0100, Colorado Business Registration.  The Colorado 
Business Registration is available at www.colorado.gov/revenue. 
 
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