Form De 1378di - Application Form For Disability Insurance Elective Coverage - 2005
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1
2APPLICATION FOR DISABILITY INSURANCE ELECTIVE COVERAGE
Complete this application only if you meet the requirements as set forth in the
FOR DEPARTMENT USE ONLY
attached Information Concerning Elective Coverage.
DIEC
—
—
APPROVED:
708(b)
708.5
ACCOUNT #
*The disclosure of your Social Security Account Number is mandatory under the
EFFECTIVE DATE:
Federal Tax Reform Act of 1976.
SUBJECT
—
QUARTER
NOTE: If you require any assistance in the completion of this
SEND FORMS
application, contact the nearest Employment Tax Customer Service
DE 2515, DE 3816DI,
DE 3DI QTR(S)
Office of this Department, or call (916) 654-6288. Upon completion of
DATE FORMS SENT:
APPROVED BY:
APPROVAL DATE:
the application, return to: Employment Development Department,
Taxpayer Assistance Center, Attn: DIEC Unit, P.O. Box 2068,
ON-LINED BY:
ON-LINED DATE:
Rancho Cordova, CA 95741-2068
PLEASE TYPE OR PRINT ALL INFORMATION CLEARLY
1.
SOCIAL SECURITY NUMBER*
2.
CALIF. EMPLOYER ACCOUNT NUMBER
3.
SEX
YEAR OF BIRTH
—
—
—
—
MALE
FEMALE
4.
YOUR NAME
FIRST
MIDDLE INITIAL
LAST
5.
HAVE YOU APPLIED FOR ELECTIVE
COVERAGE BEFORE?
YES
NO
IF YES,
MO
YR.
6.
MAILING ADDRESS: NUMBER OR P.O. BOX, STREET
CITY
ZIP CODE
7.
BUSINESS NAME (IF ANY)
BUSINESS TELEPHONE
(
)
8.
BUSINESS ADDRESS: NUMBER OR P.O. BOX, STREET
CITY
ZIP CODE
9.
EMAIL ADDRESS:
10. WEB PAGE ADDRESS:
11. DO YOU HAVE ANY EMPLOYEES?
IF YES, AND YOU ARE NOT REGISTERED WITH THIS DEPARTMENT AS AN EMPLOYER, PLEASE EXPLAIN:
YES
NO
12. TYPE OF ORGANIZATION:
CORPORATION - DO NOT SUBMIT, CORPORATE OFFICERS ARE EMPLOYEES AND COVERED UNDER THE STATE DISABILITY INSURANCE PROGRAM.
GENERAL PARTNERSHIP (INCLUDES HUSBAND AND WIFE CO-OWNERS WHO ARE BOTH ACTIVE IN THE OPERATION AND MANAGEMENT OF
THE BUSINESS).
INDIVIDUAL
LIMITED PARTNERSHIP - ONLY GENERAL PARTNER MAY APPLY
13. NAME(S) AND TITLE OF ALL PARTNERS (CONTINUE ON ANOTHER PAGE IF NECESSARY)
GENERAL PARTNERS
Social Security Number*
LIMITED PARTNERS
Social Security Number*
14. NATURE OF BUSINESS:
CONTRACTING
MANUFACTURING
REPAIRING
RETAIL TRADE
SERVICE
WHOLESALE TRADE
OTHER (DESCRIBE)
15. YOUR OCCUPATION/TITLE
16. DESCRIBE THE TYPE OF SERVICE, TYPE OF CONTRACTING, OR PRODUCT SOLD.
17. IS A LICENSE OR PERMIT REQUIRED IN YOUR TRADE, BUSINESS OR OCCUPATION?
DO YOU POSSESS SUCH A VALID
PROVIDE LICENSE/PERMIT NUMBER
YES
NO
IF YES, INDICATE TYPE OF LICENSE OR PERMIT REQUIRED:
AND ACTIVE LICENSE?
YES
NO
19. DO YOU EXPECT TO REMAIN IN BUSINESS FOR THE NEXT EIGHT (8) CALENDAR
18. ARE YOU CONDUCTING A SEASONAL TYPE OF BUSINESS?
QUARTERS?
YES
NO
IF YES, DO NOT SUBMIT, YOU ARE NOT ELIGIBLE FOR THIS
YES
NO
IF NO, DO NOT SUBMIT, YOU ARE NOT ELIGIBLE FOR
COVERAGE. SEE INFORMATION SHEET ATTACHED.
THIS COVERAGE. SEE INFORMATION SHEET ATTACHED.
20. DO YOU PERFORM SERVICES IN YOUR TRADE, BUSINESS, OR OCCUPATION CONTINUOUSLY
IF NO, EXPLAIN.
THROUGHOUT THE YEAR? (INCLUDE TIME SPENT DOING OFFICE WORK, SOLICITING CUSTOMERS
AND MAINTAINING MACHINERY AND EQUIPMENT.)
YES
NO
DE 1378DI Rev. 41 (2-05) (INTERNET)
Page 1 of 4
CU
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