TY 2021 Form 990EZ

- TIN:

Form990EZ

Department of the Treasury
Internal Revenue Service

Short Form
Return of Organization Exempt From Income Tax

Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations)

Do not enter social security numbers on this form as it may be made public.

Go to www.irs.gov/Form990EZ for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public
Inspection

For the 2021 calendar year, or tax year beginning 07-01-2021, and ending 06-30-2022

Check if applicable:

Address change

Name change

Initial return

Final return/terminated

Amended return

Application pending

C Name of organization
COLORADO SELF-INSURER'S ASSOCIATION

Number and street (or P. O. box, if mail is not delivered to street address)PO BOX 1575-630
Room/suite

City or town, state or province, country, and ZIP or foreign postal code COLORADO SPRINGS, CO809011575

D Employer identification number

84-1120497

E Telephone number

(719) 385-5669

F Group Exemption
Number bullet

G Accounting Method: CashAccrualOther (specify) bullet

H Check bullet

required to attach Schedule B
(Form 990, 990-EZ, or 990-PF).I Website: bullet

WWW.CO-SIA.ORGJ Tax-exempt status (check only one) - 501(c)(3) 501(c)( 6) bullet

(insert no.) 4947(a)(1) or 527

K Form of organization: CorporationTrustAssociationOther

L Add lines 5b, 6c, and 7b to line 9 to determine gross receipts. If gross receipts are $200,000 or more, or if total assets (Part II, column (B) below) are $500,000 or more, file Form 990 instead of Form 990-EZ ........................... bullet

$ 25,865

Part Ⅰ

Revenue, Expenses, and Changes in Net Assets or Fund Balances (see the instructions for Part I) Check if the organization used Schedule O to respond to any question in this Part I.....................

1	Contributions, gifts, grants, and similar amounts received ....................	1
2	Program service revenue including government fees and contracts ................	2
3	Membership dues and assessments .............................	3	19,718
4	Investment income ....................................	4
5a	Gross amount from sale of assets other than inventory .......	5a
b	Less: cost or other basis and sales expenses ............	5b
c	Gain or (loss) from sale of assets other than inventory (Subtract line 5b from line 5a) ......	5c
6	Gaming and fundraising events
a	Gross income from gaming (attach Schedule G if greater than $15,000)	6a
b	Gross income from fundraising events (not including $ of contributions from fundraising events reported on line 1) (attach Schedule G if the			sum of such gross income and contributions exceeds $15,000) ..	6b	6,147
c	Less: direct expenses from gaming and fundraising events ...	6c	5,495
d	Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract line 6c)	6d	652
7a	Gross sales of inventory, less returns and allowances ......	7a
b	Less: cost of goods sold .............	7b
c	Gross profit or (loss) from sales of inventory (Subtract line 7b from line 7a) .........	7c
8	Other revenue (describe in Schedule O) ....................	8
9	Total revenue. Add lines 1, 2, 3, 4, 5c, 6d, 7c, and 8 ..............	9	20,370

10	Grants and similar amounts paid (list in Schedule O) ................	10
11	Benefits paid to or for members ......................	11
12	Salaries, other compensation, and employee benefits ................	12
13	Professional fees and other payments to independent contractors ............	13	29,345
14	Occupancy, rent, utilities, and maintenance ...................	14
15	Printing, publications, postage, and shipping ...................	15
16	Other expenses (describe in Schedule O) ...................	16	10,744
17	Total expenses. Add lines 10 through 16 .................	17	40,089

18	Excess or (deficit) for the year (Subtract line 17 from line 9) ............	18	-19,719
19	Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with
	end-of-year figure reported on prior year’s return) .................	19	34,188
20	Other changes in net assets or fund balances (explain in Schedule O) ...........	20	0
21	Net assets or fund balances at end of year. Combine lines 18 through 20 ..........	21	14,469

For Paperwork Reduction Act Notice, see the separate instructions.

Cat. No. 10642I Form 990-EZ (2021)

Form 990-EZ (2021)

Page 2

Part ⅡBalance Sheets (see the instructions for Part II)Check if the organization used Schedule O to respond to any question in this Part II.................

(A) Beginning of year(B) End of year

22Cash, savings, and investments................

34,188

14,469

23Land and buildings....................

24Other assets (describe in Schedule O) ..........

25Total assets......................

34,188

14,469

Total liabilities (describe in Schedule O) .............

27Net assets or fund balances (line 27 of column (B) must agree with line 21)

34,188

14,469

Part ⅢStatement of Program Service Accomplishments (see the instructions for Part III) Check if the organization used Schedule O to respond to any question in this Part III . .	Expenses (Required for section 501(c)(3) and 501(c)(4) organizations; optional for others.)
What is the organization's primary exempt purpose? IMPROVE BUSINESS CONDITIONS AND EDUCATE.
Describe the organization’s program service accomplishments for each of its three largest program services, as measured by expenses. In a clear and concise manner, describe the services provided, the number of persons benefited, and other relevant information for each program title.
28 EDUCATED SELF INSURED COMMUNITY REGARDING SOUND POLICY, SELF INSURANCE AND WORKERS COMPENSATION LAWS. PROMOTED EFFECTIVE CLAIMS HANDLING, MEDICAL MANAGEMENT AND SAFETY. (Grants $ 0) If this amount includes foreign grants, check here ...			28a	5,495
29 PROMOTED AND ENCOURAGED COOPERATION WITH CONSTITUTED AUTHORITIES UNDER ALL APPLICABLE WORKERS COMPENSATION LAWS FOR THE GENERAL WELFARE OF ITS MEMBERS AND THEIR EMPLOYEES. (Grants $ 0) If this amount includes foreign grants, check here ...			29a	0
30 WORKED WITH PUBLIC POLICY MAKERS TO PROMOTE TIMELY, EFFECTIVE & EFFICIENT PROGRAMS TO RETURN INJURED EMPLOYEES TO WORK WHILE CONTAINING COSTS, IMPACTING UPWARDS OF 300,000 EMPLOYEES. (Grants $ 0) If this amount includes foreign grants, check here ...			30a	28,345
31 Other program services (describe in Schedule O) ................ (Grants $ ) If this amount includes foreign grants, check here...	31a
32 Total program service expenses (add lines 28a through 31a)..........	32	33,840

Part Ⅳ

List of Officers, Directors, Trustees, and Key Employees (list each one even if not compensated ; see the instructions for Part IV)Check if the organization used Schedule O to respond to any question in this Part IV............

(a) Name and title	(b) Average hours per week devoted to position	(c) Reportable compensation (Forms W-2/1099-MISC) (if not paid, enter -0-)	(d) Health benefits, contributions to employee benefit plans, and deferred compensation	(e) Estimated amount of other compensation
BILL RUSH PRESIDENT	1.00	0	0	0
ALAN HUTCHINS LEGISLATIVE CHAIR	1.00	0	0	0
DEE ANN PFIFER VICE PRESIDENT, MEETINGS	1.00	0	0	0
HEATHER KEITH SECRETARY	1.00	0	0	0
DEBBY ESLER MEMBERSHIP	1.00	0	0	0
DAVID MILLER TREASURER	5.00	0	0	0
PAUL FELD PROFESSIONAL MEMBER	1.00	0	0	0

Form 990-EZ (2021)

Page 3

Part Ⅴ

Other Information

(Note the Schedule A and personal benefit contract statement requirements in the

instructions for Part V.) Check if the organization used Schedule O to respond to any question in this Part V.......

Yes

Did the organization engage in any significant activity not previously reported to the IRS? If "Yes," provide a detailed description of each activity in Schedule O ...................

Were any significant changes made to the organizing or governing documents? If "Yes," attach a conformed copy of the amended documents if they reflect a change to the organization’s name. Otherwise, explain the changeon Schedule O. See instructions. ..........................

35a

Did the organization have unrelated business gross income of $1,000 or more during the year from business activities (such as those reported on lines 2, 6a, and 7a, among others)? ............

35a

If "Yes," to line 35a, has the organization filed a Form 990-T for the year? If "No," provide an explanation in Schedule O

35b

Was the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization subject to section 6033(e) notice, reporting, and proxy tax requirements during the year? If "Yes," complete Schedule C, Part III Click to see attachment

35c

Yes

Did the organization undergo a liquidation, dissolution, termination, or significant disposition of net assets during the year? If “Yes," complete applicable parts of Schedule N ................

37a

Enter amount of political expenditures, direct or indirect, as described in the instructions. bullet

37a

Did the organization file Form 1120-POL for this year?...................

37b

38a

Did the organization borrow from, or make any loans to, any officer, director, trustee, or key employee or were

any such loans made in a prior year and still outstanding at the end of the tax year covered by this return?..

38a

If “Yes," complete Schedule L, Part II and enter the total amount involved .

38b

Section 501(c)(7) organizations. Enter:

Initiation fees and capital contributions included on line 9.......

39a

Gross receipts, included on line 9, for public use of club facilities.....

39b

40a

Section 501(c)(3) organizations. Enter amount of tax imposed on the organization during the year under:

section 4911 bullet

; section 4912 bullet

; section 4955 bullet

Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Did the organization engage in any section 4958 excess benefit transaction during the year, or did it engage in an excess benefit transaction in a prior year that has not been reported on any of its prior Forms 990 or 990-EZ? If “Yes," complete Schedule L, Part I

40b

Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Enter amount of tax imposed on organization managers or disqualified persons during the year under sections 4912, 4955, and 4958 bullet

Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Enter amount of tax on line 40c reimbursed by the organization bullet

All organizations. At any time during the tax year, was the organization a party to a prohibited tax shelter transaction? If "Yes," complete Form 8886-T ................

40e

41List the states with which a copy of this return is filed. bullet

42a The organization's books are in care of bullet

DAVID MILLER
Telephone no. bullet

(719) 385-5661

Located at bullet

PO BOX 1575-303COLORADO SPRINGS, CO ZIP + 4 bullet

80901

Yes

At any time during the calendar year, did the organization have an interest in or a signature or other authority over a financial account in a foreign country (such as a bank account, securities account, or other financial account)? . .

42b

If “Yes," enter the name of the foreign country: bullet

See the instructions for exceptions and filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR).

At any time during the calendar year, did the organization maintain an office outside the U.S.? . . .

42c

If “Yes," enter the name of the foreign country: bullet

43 Section 4947(a)(1) nonexempt charitable trusts filing Form 990-EZ in lieu of Form 1041 - Check here ...... bullet

and enter the amount of tax-exempt interest received or accrued during the tax year .... bullet

Yes

44a

Did the organization maintain any donor advised funds during the year? If "Yes," Form 990 must be completed insteadof Form 990-EZ.............................

44a

Did the organization operate one or more hospital facilities during the year? If "Yes," Form 990 must be completedinstead of Form 990-EZ.............................

44b

Did the organization receive any payments for indoor tanning services during the year? .........

44c

If "Yes," to line 44c, has the organization filed a Form 720 to report these payments? If "No," provide an
explanation in Schedule O ............................

44d

45a

Did the organization have a controlled entity within the meaning of section 512(b)(13)?.........

45a

45b

Did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," Form 990 and Schedule R may need to be completed instead of Form 990-EZ (see instructions)......................

45b

Form 990-EZ (2021)

Page 4

Yes

Did the organization engage, directly or indirectly, in political campaign activities on behalf of or in opposition to candidates for public office? If “Yes," complete Schedule C, Part I. Click to see attachment

...........

Part Ⅵ

Section 501(c)(3) Organizations Only All section 501(c)(3) organizations must answer questions 47- 49b and 52, and complete the tables for lines 50 and 51. Check if the organization used Schedule O to respond to any question in this Part VI ..................

Yes

Did the organization engage in lobbying activities or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part II .......................

Is the organization a school as described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E ..

49a

Did the organization make any transfers to an exempt non-charitable related organization?......

49a

If "Yes," was the related organization a section 527 organization?................

49b

Complete this table for the organization's five highest compensated employees (other than officers, directors, trustees and key employees) who each received more than $100,000 of compensation from the organization. If there is none, enter "None."

(a) Name and title of each employee	(b) Average hours per week devoted to position	(c) Reportable compensation (Forms W-2/1099-MISC)	(d) Health benefits, contributions to employee benefit plans, and deferred compensation	(e) Estimated amount of other compensation

Total number of other employees paid over $100,000 ............. bullet

Complete this table for the organization's five highest compensated independent contractors who each received more than $100,000 of compensation from the organization. If there is none, enter "None."

(a) Name and business address of each independent contractor	(b) Type of service	(c) Compensation

Total number of other independent contractors each receiving over $100,000.......... bullet

Did the organization complete Schedule A? NOTE. All section 501(c)(3) organizations must attach a
completed Schedule A ........................................ bullet

Yes No

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.

Sign Here

	Signature of officer	Date

	Type or print name and title

Paid Preparer Use Only

Print/Type preparer's name

Preparer's signature

Date

Check if
self-employed

PTIN

Firm's name bullet

Firm's EIN bullet

Firm's address bullet

Phone no.

May the IRS discuss this return with the preparer shown above? See instructions ......... bullet

YesNo

Form 990-EZ (2021)

Additional Data

Software ID:
Software Version:

Form 990-EZ, Special Condition Description:

Special Condition Description

- TIN:

SCHEDULE C
(Form 990)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527

SchCMd Bullet

Complete if the organization is described below. SchCMd Bullet

Attach to Form 990 or Form 990-EZ.
SchCMd Bullet

Go to www.irs.gov/Form990 for instructions and the latest information.

OMB No. 1545-0047

2021

Open to Public
Inspection

If the organization answered "Yes" on Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered "Yes" on Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered "Yes" on Form 990, Part IV, Line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

COLORADO SELF-INSURER'S ASSOCIATION

Employer identification number

84-1120497

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV. See instructions for definition of “political campaign activities."

Political campaign activity expenditures. See instructions .................................................................... SchCMd Bullet

Volunteer hours for political campaign activities. See instructions ..................................................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ................................ SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ....................... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? .........................................

Yes No

Was a correction made? ......................................................................................................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c), except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities ..... SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ............................................................................................................................ SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b........... SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ...................................................................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.
1
2
3
4
5
6

For Paperwork Reduction Act Notice, see the instructions for Form 990.

Cat. No. 50084S

Schedule C (Form 990) 2021

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......................
b	Total lobbying expenditures to influence a legislative body (direct lobbying) ........................
c	Total lobbying expenditures (add lines 1a and 1b) ............................................................
d	Other exempt purpose expenditures ...............................................................................
e	Total exempt purpose expenditures (add lines 1c and 1d) ..................................................
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................................................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................................................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................................................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ...................................................................................................................	Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2018	(b) 2019	(c) 2020	(d) 2021	(e) Total

2a	Lobbying nontaxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990) 2021

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each "Yes" response on lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes|No

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? ...........................................................................................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ........

Media advertisements? ...................................................................................................

Mailings to members, legislators, or the public? .............................................................................

Publications, or published or broadcast statements? ...........................................................

Grants to other organizations for lobbying purposes? ..........................................................

Direct contact with legislators, their staffs, government officials, or a legislative body? .......................

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ..................

Other activities? ...................................................................................................................

Total. Add lines 1c through 1i ....................................................................................................

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 ...........................................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 ...................

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? ........................

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ...............................................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ............................................

Did the organization agree to carry over lobbying and political expenditures from the prior year? .................................

Yes

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No" OR (b) Part III-A, line 3, is answered “Yes."

Dues, assessments and similar amounts from members ......................................................................

25,073

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for which the section 527(f) tax was paid).

Current year .............................................................................................................................

28,345

Carryover from last year ............................................................................................................

8,884

Total ...........................................................................................................................................

37,229

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

16,047

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ......................................................................................................................

9,026

Taxable amount of lobbying and political expenditures. See Instructions .........................................

Part IV

Supplemental Information

Provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, lines 1 and 2 (see instructions), and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation

Schedule C (Form 990) 2021

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or 990-EZ or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Go to www.irs.gov/Form990 for the latest information.

OMB No. 1545-0047

2021

Open to Public
Inspection

Name of the organization

COLORADO SELF-INSURER'S ASSOCIATION

Employer identification number

84-1120497

Return Reference	Explanation
FORM 990-EZ, PART I, LINE 16 - OTHER EXPENSES	DESCRIPTION: BUSINESS MEETINGS. AMOUNT: 983. DESCRIPTION: WEB MAINTENANCE. AMOUNT: 2,828. DESCRIPTION: BANK CHARGES. AMOUNT: 711. DESCRIPTION: INSURANCE. AMOUNT: 170. DESCRIPTION: MISCELLANEOUS. AMOUNT: 3,408. DESCRIPTION: MARKETING. AMOUNT: 2,644. TOTAL TO FORM 990-EZ, LINE 16: 10,744.

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990) 2021

Additional Data

Software ID:
Software Version:

- TIN:

TY 2021 TransferPrsnlBnftContractsDecl

Name:

COLORADO SELF-INSURER'S ASSOCIATION

EIN:

84-1120497

Declaration:

THE ORGANIZATION DID NOT, DURING THE YEAR, RECEIVE ANY FUNDS, DIRECTLY,OR INDIRECTLY, TO PAY PREMIUMS ON A PERSONAL BENEFIT CONTRACT.THE ORGANIZATION, DID NOT, DURING THE YEAR, PAY ANY PREMIUMS, DIRECTLY,OR INDIRECTLY, ON A PERSONAL BENEFIT CONTRACT.