Payroll Changes

To request a payroll change, please complete the form below or download a PDF version of the form and FAX the completed form to CIG (720.962.8800).

DOWNLOAD PDF FORM

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To ensure the most current information for your policy, please complete the below form
in its entirety and send it back to us as soon as possible.

Contact Name (required)

Company Name (required)

Policy Number (required)

Policy Period (required)

Projected Annual Sales/Gross Receipts:

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Class Code 1

Description 1

Payroll Amount 1

Number of Part Time Employees 1

Number of Full Time Employees 1

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Class Code 2

Description 2

Payroll Amount 2

Number of Part Time Employees 2

Number of Full Time Employees 2

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Class Code 3

Description 3

Payroll Amount 3

Number of Part Time Employees 3

Number of Full Time Employees 3

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Class Code 4

Description 4

Payroll Amount 4

Number of Part Time Employees 4

Number of Full Time Employees 4

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OFFICER INFORMATION

Change in Ownership?
 Yes No

Name 1

SSN 1

Title 1

% Owed 1

Include or Exclude 1

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Name 2

SSN 2

Title 2

% Owed 2

Include or Exclude 2

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Name 3

SSN 3

Title 3

% Owed 3

Include or Exclude 3

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Name 4

SSN 4

Title 4

% Owed 4

Include or Exclude 4

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Security Check — please enter this code:
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Coverage cannot be bound or changed via fax, e-mail or CIG website.
CIG staff will contact you for verification and/or additional questions regarding your request.