Voluntary Election To Extend The Coverage Of The Washington Employment Security Act Form printable pdf download

VOLUNTARY ELECTION TO EXTEND THE COVERAGE OF THE WASHINGTON

EMPLOYMENT SECURITY ACT

Please complete and return this form to the:

Employment Security Department

UI Tax and Wage Administration/Status

P.O. Box 9046

Olympia, Washington 98507-9046

This agreement to elect coverage becomes binding upon the approval by the agency. If the agreement is approved, a copy will be returned to

you signed by an authorized representative. Do not report the personnel stated below until you have received authorization from the agency. If

your application cannot be approved, you will be notified of the reason. The Washington Administrative Code (WAC) lists reasons why

voluntary coverage may not be approved and why it may be cancelled after it is approved (see reverse or next page).

Please answer completely each of the following questions:

Business name

Mailing address

If you are already an employer subject under the Washington Employment Security Act, please indicate your Employment Security (ES)

Reference No.

, and/or your Unified Business Identifier No.

Provide the type(s) of non-covered employment below in which you presently employ workers you want covered and the number of all

workers in employment in that same business or part there of.

Type(s) of Employment to be Covered (Check one and/or specify)

No. Employed

Corporate Officers

All Individuals

Distinct Class of Individuals

Other (specify)

If you represent a corporation, please complete all current corporate officers data requested on the reverse or next page of this form.

NOTE: For voluntary coverage, the law requires that all corporate officers be covered as a group.

The undersigned, an employer or prospective employer under the Washington Employment Security Act, pursuant to the terms

RCW 50.24.160

and provisions of

, does hereby voluntarily elect to extend the application of the law to workers in noncovered

employment, and requests written approval of such election by the Employment Security Department of Washington, to be

effective as of:

____________________________________________________________

(Signature of Corporate Officer or Business Owner)

(Business Phone)

(Title)

(Date of Application)

This application MUST be signed by a Corporate Officer or Business Owner. Voluntary Coverage is effective until terminated by the

employer or cancelled by the agency. Coverage must remain in effect for a MINIMUM OF TWO CALENDAR YEARS. A request for

termination by the employer must be in writing and postmarked by January 15, immediately following the end of the last year of desired

coverage. In the event that your taxes become delinquent, the agency reserves the right to cancel your Voluntary Coverage.

Approved by the Commissioner of Washington Employment Security Department to become effective from

________________________________________________________________

(Date of Approval)

(Authorized Representative of the Commissioner)

(See reverse or next page)

EMS 5203 (Rev. 2/05) CC 7540-032-139

Voluntary Election To Extend The Coverage Of The Washington Employment Security Act Form

Related Articles

Related forms

Related Categories