Form De 1378 - Application For Unemployment And Disability Insurance Elective Coverage For Employees Excluded Under The California Unemployment Insurance Code (Cuic)
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Account Number
Statistical Code
APPLICATION FOR UNEMPLOYMENT AND DISABILITY
Subject Quarter
INSURANCE ELECTIVE COVERAGE FOR EMPLOYEES
Send Forms
Sent Forms
EXCLUDED UNDER THE CALIFORNIA UNEMPLOYMENT
Classified By
Date
INSURANCE CODE (CUIC)
Return this form to:
Employment Development Department
Taxpayer Assistance Center
Attention: Specialized Coverage Desk
PO Box 2068
Rancho Cordova, CA 95741-2068
888-745-3886
This form is not an application for an account number. Submit a Commercial Employer Account Registration and Update Form,
1, to
DE
obtain an account number. If you are a nonprofit organization, please refer to question 14.
Complete this form only if all of the following exists:
Your employees are engaged in employment excluded under the CUIC.
A majority of your employees who are engaged in excluded employment want to be covered by the provisions of the CUIC and
you agree to such coverage. All employees in any establishment or location must be covered by the election.
You and your employees want this coverage to be effective for at least two complete calendar years after the effective date of
this agreement.
1. Business Name:
(Phone)
2. Business Address:
(Street)
(City)
(State) (ZIP Code)
3. Mailing Address:
(Street)
(City)
(State) (ZIP Code)
4. Type of Organization: Individual
Partnership: General
Limited
Corporation: Domestic
Foreign
Other
Limited Liability Company (LLC) treated for federal income tax reporting purposes as:
Disregarded Entity
Partnership
Corporation
5. Indicate Owner(s), Corporation Officer(s), Partner(s), Member(s), etc. (Use additional sheets if necessary.)
FIRST and LAST NAME
TITLE
RESIDENCE ADDRESS
6. Check the box for any type of service you want to include under elective coverage:
Domestic services in a private home where such individual receives less than $1,000 cash remuneration in a calendar quarter
(Section 629 of the CUIC). (An individual who receives at least $750 in cash remuneration is mandatorily covered for disability
insurance under Section 2606.5 of the CUIC).
Services as a transcriber of depositions, court proceedings, and hearings performed away from the office of the person, firm, or
association obligated to produce a transcript of these proceedings (Section 630 of the CUIC).
Services described in Section 634.5 of the CUIC:
In the employ of a church, convention or association of churches, or an organization operated primarily for religious
purposes and is operated, supervised, controlled, or principally supported by a church or convention of churches.
By a duly ordained, commissioned, or licensed minister or member of religious order.
DE 1378 Rev. 34 (8-16) (INTERNET)
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