Form De 1378 - Application For Unemployment And Disability Insurance Elective Coverage For Employees Exempted Under The California Unemployment Insurance Code - 2005 Page 2
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2Services for an organization exempt from income tax if remuneration for such service is less that $50 in any
calendar quarter (Section 641).
Services performed in the employ of a school, college or university if such service is performed (Section 642).
(a) By a student regularly attending classes at such college or university.
(b) By a spouse of such student in a program to provide financial assistance to such student. (To be excluded, the
spouse must be so advised at commencement of services.)
Service performed as a student nurse in the employ of a hospital or nurses’ training school (Section 645).
Service performed as an intern in the employ of a hospital (Section 645).
Service in a program combining academic instruction and work experience (Section 646).
Service performed for a hospital by a patient (Section 647).
Service on other than an American vessel or aircraft and the service therewith is performed outside the United States
(Section 648).
7. Is your business seasonal?
. If "yes," during what months do you operate?
8. Do you expect to remain in business for the next eight calendar quarters?
9. Indicate the number of different locations at which your activities are conducted in California
Show locations covered by this application
10. (a)
Do you have any employees in California that you do not want included in this coverage?
If "yes," what work do they do?
(b)
Do these employees perform services at the same establishment or location as those in Item 9?
If "no," identify the establishment or location at which the services are performed.
11. How many employees will be covered by this agreement?
Disregard Items 12 and 13 if deductions from your employees’ wages are already required for disability insurance purposes.
12. SDI deductions should not be made from your employees’ wages for the purpose of paying contributions until your
application has been approved. If deductions have already been made, show the beginning date
and the
amount $
.
13. Were such SDI deductions made on all employees covered by this application?
14. Is this a nonprofit organization?
Yes
No If yes, is it exempt under Section 501(c)(3) of the Internal Revenue Code?
If yes, submit form DE 1SNP, Selection of Financing Method by a Nonprofit Organization.
15. On what date do you wish elective coverage to commence?
First day of current quarter
First day of next quarter
The undersigned hereby elects and makes application, under the Unemployment Insurance Code, to become an employer
subject to the CUIC with respect to all employment as set forth in this elective coverage agreement. It is understood that upon
approval of this election by the Director the undersigned will be subject to the CUIC as of the date specified in the approval and
will continue to be subject for at least two complete calendar years after the effective date of this agreement and thereafter until
this elective coverage is terminated as provided by the CUIC.
I declare that this application has been examined by me and, to the best of my knowledge and belief, is true and correct and
made in good faith under the provisions of the CUIC, and that I have posted form DE 1375 (Notice to Employees) in a
prominent place on my premises.
This declaration must be signed by one or
Signed
Date
more persons shown under Item 5. If the
application is a partnership all partners
must sign the application. If there are
Date
more than three partners, attach a
separate sheet bearing the signatures and
addresses of such additional partners.
Date
DE 1378 Rev. 33 (3-05) (INTERNET)
Page 2 of 4
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