Answer a few simple questions to find out if you are entitled to 90% pay, up to $1,324 a week, for 3 months.

Do you work primarily within Colorado? *

Yes

No

Have you made more than $2,500 at the same employer (including self-employed)?

Yes

No

If you do not work primarily in Colorado, do you work PRIMARILY within ONE other state BESIDES Colorado?

Yes

No

On your paycheck, does it say FAMLI?

Yes

No

Is your base of operations in Colorado?

Yes

No

Does your employer direct your work from Colorado?

Colorado

Another State

Is your residence in Colorado?

Yes

No

Does your employer direct your work from a state where you also work?

Yes

No

Are you willing to work on your mental health either through therapy, medications, or advanced treatment options?

Yes

No

Where should we send your results?

First Name

Last Name

Email *

Phone *

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