Taxpayer Assistance Center, Attn: Specialized Coverage Desk/P.O. Box 2068, Rancho Cordova,
CA 95741-2068 / (916) 654-6288
For Department Use Only
Account No.
Application for Elective Coverage of Disability
Statistical Code
Insurance* Only for Employees of a Public School
Effective Date
Employer Under Section 710.4 or a Public Agency
Approved By
Employer Under Section 710.5 or an
Date
Indian Tribe under Section 710.6 or a Community College District
Employer Notified
under Section 710.9 of the California Unemployment Insurance Code
(Date)
Send
Number of Employees
IMPORTANT
This form is not an application for an account number under the compulsory provisions of the Unemployment Insurance Code.
Do not complete this form unless you wish to apply for Disability Insurance coverage ONLY under Section 710.4, 710.5, 710.6, or
710.9 for your employees. Coverage under these sections of the Code does not make provision for Unemployment Insurance
benefits.
NOTE: If your application is approved, the elective coverage agreement will be subject to all of the requirements and conditions
outlined in form DE 1378P, "Information Concerning Elective Coverage Under Section 710.4, 710.5, 710.6, or 710.9 of the
Unemployment Insurance Code." Please retain your copy of form DE 1378P for reference.
******************
Please Type or Print
1.
Name of Employer
(Telephone)
2.
Business Address
(Street and Number)
(City)
(County)
(State)
(ZIP Code)
3.
Mailing Address
(Street and Number)
(City)
(County)
(State)
(ZIP Code)
4.
Type of Employer – (Check one)
Public School – Section 710.4
Indian Tribe – Section 710.6
Public Agency – Section 710.5
Community College District – Section 710.9
5.
Law under which agency was established. (Does not apply to Indian Tribes)
(a) California General Laws
Title of Act
Number
Year Enacted
OR
(b) California Codes
Title of Code
Number
Part
Chapter
Sections
to
6.
Members of governing body of the employer.
Name
Title
Residence Address
*Includes Paid Family Leave (PFL) beginning January 1, 2004.
DE 1378N Rev. 12 (1-10) (INTERNET)
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