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UCS-2A

Questionnaire For Voluntary Election of

R. 09/01

Unemployment Compensation Coverage

Owner name _____________________________________________________________________

(Legal name of individual, principal partner, or corporation)

Mailing address___________________________________________________________________

(Street address/City/State/Zip)

1. What personal property and equipment does the applicant own? List and state value:

____________________________________________________________________________________

2. What real property does the applicant own? (Building and fixtures) _______________________________

____________________________________________________________________________________

If building and or fixture are leased, when does lease expire? ___________________________________

Does the lease contain a renewal clause? __________________________________________________

3. Give a brief statement in the employer’s own words as to why the coverage is desired:

____________________________________________________________________________________

4. Is there an occupational license? _________________________________________________________

In whose name is it issued? _____________________________________________________________

5. If the business was purchased, was it paid for in cash? _______ If not, is there a balance due?________

(a) If a balance is due, how much? ____________________________________________________

(b) Is there any delinquency regarding the purchase due the previous owner? __________________

6. Is the business making a profit? ______________________ Are current bills paid? _________________

Are there substantial amounts outstanding? _____________ If yes, explain. _______________________

____________________________________________________________________________________

7. List any relatives of the owner who are employed by the unit. ___________________________________

____________________________________________________________________________________

8. If the unit is a corporation, are any of the majority stockholders or their families employed and

drawing wages? ______________ If yes, list stockholders, employee’s name(s) and relationship to

stockholder. _________________________________________________________________________

____________________________________________________________________________________

9. Does the unit normally operate throughout the entire year? _____________________________________

If no, explain. _________________________________________________________________________

10. Have the employees of the business made overtures to the employer to be covered in the

Unemployment Compensation program? ___________________________________________________

Owner name ________________________________________

(Legal name of individual, principal partner, or corporation)

By ________________________________________________

Date ____________________________________

Tax Auditor _______________________________

Title _______________________________________________

Internet Address:

Ucs-2a - Questionnaire For Voluntary Election Of Unemployment Compensation Coverage Form