Form Ui-1b - Voluntary Election Of Coverage Under The Illinois Unemployment Insurance Act Page 2

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10. The undersigned employing unit does hereby elect, pursuant to the terms and provisions of Section 205(h) of the Illinois

Unemployment Insurance Act: (Check one)

a. To become an employer liable for the payment of contributions under the Illinois Unemployment Insurance Act to the

same extent as any other employer.

b. To become an employer liable for the payment of contributions under the Act AND to extend coverage under the Act to

workers in excluded employment.

c. To extend coverage under the Act to workers in excluded employment.

The undersigned employing unit hereby makes application for the approval of such election by the Director of Employment

Security as of: (Check one)

January 1

of the current year

The date workers were first employed in the current year

The following date in the present year if (c) above is checked

Business Name:

Signed by:

Official title:

Telephone:

Date Signed:

This election must be signed by owner, partner or officer.

If signed by any other person, a power of attorney giving such

individual authority to sign must be attached.

NOTE: Upon approval of your election by the Director of Employment Security, you will become liable for the payment of

contributions on the wages of your workers for at least two calendar years.

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OFFICIAL NOTIFICATION OF THE DIRECTOR’S DECISION REGARDING THIS REQUEST WILL BE MAILED TO YOU.

This state agency is requesting information that is

necessary to accomplish the statutory purpose as

outlined under 820 IL CS 405/100-3200. Disclosure of

this information may result in statutorily prescribed

liability and sanctions, including penalties and /or

interest.

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