Form Ucs-6c - Employee'S Consent Form Reciprocal Coverage Election printable pdf download

Form Ucs-6c - Employee'S Consent Form Reciprocal Coverage Election

UCS-6C

Employee’s Consent Form

R. 07/07

Reciprocal Coverage Election

Social

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Employee’s Name: ______________________________________ Security No.

Residence Address: _____________________________________________________________________________________

City, State ZIP: _ _________________________________________________________________________________________

Inasmuch as I customarily perform services for:

Employer’s Name: _ ______________________________________________________________________________________

Employer’s Address: _ ____________________________________________________________________________________

City, State ZIP: _ _________________________________________________________________________________________

in more than one state, I the undersigned, concur in my employer’s request that my services for the purpose

of unemployment compensation be deemed to be performed entirely within the State of Florida effective as of

________________________, and hereby consent to such determination. This coverage is to remain in effect until such

time as the conditions of my employment with respect to where my services are performed change to the extent that I

no longer customarily perform services in more than one state, or the agreement is otherwise terminated.

Date: ___________________________ Signed: _______________________________________________________________

Form Ucs-6c - Employee'S Consent Form Reciprocal Coverage Election