Form Ui-1b - Voluntary Election Of Coverage Under The Illinois Unemployment Insurance Act

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Voluntary Election of Coverage under the Illinois Unemployment Insurance Act
An agreement to elect coverage becomes binding upon approval by the Director of Employment Security. If the election is
approved, you will be notified by mail. You will similarly be notified with a statement of the reason(s) for denial.
Type or print in ink. Sign and return original to this Department. Retain a copy for your files.
1. Name of employer
2. Address
3. Date employer began employing workers in Illinois
4. Are you, or have you been, an employer subject to the Illinois Unemployment Insurance Act?
Yes
No
If yes, enter the account number assigned to you
(IF YOU ARE A CURRENTLY LIABLE EMPLOYER, IT IS NOT NECESSARY TO COMPLETE ITEMS 5 THROUGH 8.)
5. Have you incurred liability under the Federal Unemployment Act in the last five years?
Yes
No
6. Enter the total amount of wages paid by you during the last four completed calendar quarters:
Quarter Ending:
Wages:
7. Enter, for each of the last 12 months, the number of persons performing services for you in Illinois, whose services
are defined as “employment” under the Illinois Unemployment Insurance Act. If a corporation, include corporate
officers.
Month:
No. of Workers:
8. Give the following information with respect to each individual performing services for you on the date this election form is
being prepared. If related to owner, partner or officer, give exact relationship and to whom related; if not related, enter
“none”.
Name
Social Security No.
Relationship and to Whom Related
9. If you desire to extend coverage to workers whose services are excluded from the definition of “employment” under the
Act, enter below (a) the type(s) of excluded employment performed by workers whom you wish to cover, (b) the location of
the establishment(s) where such excluded employment is performed and (c) the number of workers in excluded
employment by type, in each establishment during the most recently completed week.
(a)
(b)
(c)
Type of Excluded Employment
Location of Establishment
No. of Workers
UI-1B Voluntary Election of Coverage
Page 1 of 1
Rev. (09/2011)

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