Form Uitl-100 - Application For Unemployment Insurance Account May 2011 Page 2

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Department Use Only

Has this business paid wages or paid other remuneration in lieu of wages such as dividends (“S” corporation only), bonuses, draws, or disbursements?

Yes

NOTE: Wages include payments made to corporate officers performing any services in Colorado.

If Yes, provide the federal employer identification number (FEIN) if different than the FEIN provided in Item 4 or the UI account number if different

than the account number provided in Item 2 if applicable.

6. Has this business paid any individual who is considered to be a contractor or subcontractor?

Yes

7. Has the business issued or does it intend to issue IRS Form 1099-MISC to any individual.

Yes

If Yes to Item 6 or 7, describe the type of work performed_____________________

8. Is this business an employee-leasing company (i.e., does it lease employees to other businesses or management companies)?

Yes

9. Are the employees of this business hired through an employee-leasing company or management company?

Yes

If Yes: Provide the name of the employee-leasing or management company

Provide the FEIN and/or UI account number

10. Is this business an individual/sole proprietor?

Yes

If Yes, are there any employees other than the individual, his or her spouse, or his or her children under the age of 21?

11. Is this business a partnership or limited liability organization?

Yes

If Yes, are there any employees other than the partners or members of the limited liability organization?

Yes

12. Select the item that best describes the business’s activity in Colorado (check only one box) and provide specific detail below. For additional information

regarding these industry descriptions, call Labor Market Information (LMI) at 303-318-8850 or contact LMI in writing at 633 17

Street, Suite 600, Denver,

CO 80202. Additional information is available online at

Agricultural (list crops, animals, and/or services provided)

Construction—General Contractor

Mining (list product being mined and/or services performed)

Residential

Utilities (list type and services performed)

Single Family

Transportation, Communication, or Public Utilities (list type)

Multiple Family

Retail Trade (list type of product sold and to whom)

Commercial

Wholesale Trade (list type of product sold and to whom)

Industrial/Warehouse

Service (list type and explain in detail)

Other Commercial

Finance, Insurance, or Real Estate (list type and explain in detail)

Speculative Builder/For Sale by Owner

Manufacturing and Assembly (list materials used and products rendered)

Subcontractor (explain in detail)

Government (list type of agency)

Heavy Construction

Household/Domestic

Highway and Steel Construction

Other

Bridge, Tunnel, and/or Elevated Highway

Water, Sewer, Pipeline, and/or Communication

Other Heavy Construction

Provide specific detail regarding the business’s activity in Colorado. If more than one service is provided, indicate which is predominant.

NOTE: If the business’s entire activity is seasonal or if it has seasonal occupations, a request for seasonal designation can be made by completing and

returning Form UITL-5, Request for Seasonal Determination. To obtain this form, go to , click on Forms and Publications,

and then click on Employer Forms. If you have any questions regarding seasonal status, call us at one of the telephone numbers at the top of the initial

page of this application.

13. Worksite Information—Provide the following information for each physical location in Colorado. Do not provide P.O. boxes, payroll, or accountant

addresses. If an employee works from his or her home, you must provide the employee’s residence address. Attach additional sheets of paper for more than

one physical location in Colorado.

Complete Physical Street Address of Worksite (include city, state, and ZIP code)

Worksite Telephone Number

Worksite Contact Person

Average Number of Employees in a Typical Month

14. Business Acquisition—For purposes of this application, an acquisition is defined as the purchase or transfer of any or all of the assets and/or employees of

a previously established business. If this business entity was acquired, in accordance with CESA 8-76-104, we must make a determination regarding the

purpose of the business acquisition. If you have any questions regarding the acquisition of a business, call us at one of the telephone numbers at the top of the

initial page of this application. Enclose a copy of the sales agreement and a list of the board of directors for the new business and all acquired businesses.

Is the business entity completing this application as a result of a business acquisition?

Yes

If No, skip to Item 17.

If Yes: Provide the date of acquisition

Check one of the boxes below to indicate the type of acquisition and complete Items 15 and 16.

Total Business Acquisition or Employee Transfer—This business acquired all of the organization, trade, or business or

substantially all of the assets of at least one employer or utilizes the services of 90 percent or more of the total number of

employees from another employer.

NOTE: This can include a reorganization of a current business.

Partial Business Acquisition or Employee Transfer—This business acquired some of the organization, trade, or business or assets of

at least one employer or utilizes the services of less than 90 percent of the total number of employees from another employer.

NOTE: This can include a reorganization of a current business.