Form De 1378 - Application For Unemployment And Disability Insurance Elective Coverage For Employees Exempted Under The California Unemployment Insurance Code - 2005

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Do Not Write in This Space
Account Number
Statistical Code
APPLICATION FOR UNEMPLOYMENT AND DISABILITY
Subject Quarter
INSURANCE ELECTIVE COVERAGE FOR EMPLOYEES
Send Forms
Sent Forms
EXEMPTED UNDER THE CALIFORNIA UNEMPLOYMENT
Classified By
Date
INSURANCE CODE
Return this form to: Employment Development Department
Taxpayer Assistance Center, Attn: Specialized Coverage Desk
P.O. Box 2068
Rancho Cordova, CA 95741-2068
(916) 654-6288
This form is not an application for an account number. Submit DE 1, Registration Form, to obtain an account number and also refer
to question 14 if you are a nonprofit organization.
Complete this form only if:
• Your employees are engaged in employment exempted under the California Unemployment Insurance Code (CUIC).
• A majority of your employees who are engaged in exempt employment want to be covered by the provisions of the
CUIC and you agree to such coverage. All employees in any establishment or location must be covered by the
election.
• You and your employees want this coverage to be effective for at least two complete calendar years after the
effective date of this agreement.
1. Business name:
(Telephone)
2. Business address:
(Street)
(City)
(State)
(ZIP Code)
3. Mailing address:
(Street)
(City)
(State)
(ZIP Code)
4. Type of organization:
Individual
Partnership:
General
Limited
Corporation:
Domestic
Foreign
Other
5. Indicate Owners, Corporation Officers, Partners, etc. (Use additional sheets if necessary.)
FIRST and LAST NAME
TITLE
RESIDENCE ADDRESS
6.
Check the block for any type of service you want to include under elective coverage:
Domestic services in a private home where such individual receives less than $1,000 cash remuneration in a calendar
quarter (Section 629). (An individual who receives at least $750 in cash remuneration is mandatorily covered for
disability insurance under Section 2606.5).
Services described in Section 634.5:
(a)
For a church, convention of churches, or organization operated primarily for religious purposes.
(b)
Duly ordained, commissioned, or licensed minister or member of religious order.
(c)
Services for a rehabilitation program by a participant in the program. (Except as provided by Section 605.5)
(d)
Services in a work-relief or work-training program by a participant in that program.
(e)
Services by an inmate of a custodial or penal institution.
(f)
Services by individual under 18 years of age in the delivery or distribution of newspapers or shopping news.
(g)
Services by an individual in, and at the time of, the sale of newspapers and magazines to ultimate
consumers.
Domestic services in a local college club or local chapter of a college fraternity or sorority if the remuneration paid is
less than $1,000 cash remuneration in a calendar quarter (Section 639).
Casual labor not in the course of the employing unit’s trade or business (Section 640).
DE 1378 Rev. 33 (3-05) (INTERNET)
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