Form De 1378 - Application For Unemployment And Disability Insurance Elective Coverage For Employees Excluded Under The California Unemployment Insurance Code (Cuic) Page 3
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39. Indicate the number of different locations at which your activities are conducted in California.
List the addresses of the locations covered by this application.
10. (a) Do you have any employees in California that you do not want included in this coverage?
Yes
No
If "Yes," what work do they do?
(b) Do these employees perform services at the same establishment or location as those in Item 9?
Yes
No
If "No," identify the establishment or location at which the services are performed.
11. How many employees will be covered by this agreement?
Disregard Items 12 and 13 if deductions from your employees' wages are already required for State Disability Insurance (SDI)
purposes.
12. SDI deductions should not be made from your employees' wages for the purpose of paying contributions until your application has
been approved. If deductions have already been made, list the beginning date
and the
amount $
.
13. Were such SDI deductions made on all employees covered by this application?
Yes
No
14. Is this a nonprofit organization?
Yes
No
If “Yes,” is it exempt under Section 501(c)(3) of the
Yes
No
Internal Revenue
Code?
If “Yes,” submit the Selection of Financing Method by a Nonprofit Organization Described in Section 501(c)(3) of the Internal
Revenue Code,
1SNP, form.
DE
15. On what date do you wish elective coverage to commence?
First day of current quarter
First day of next quarter
The undersigned hereby elects and makes application, under the CUIC, to become an employer subject to the CUIC with respect to all
employment as set forth in this elective coverage agreement. It is understood that upon approval of this election by the Director the
undersigned will be subject to the CUIC as of the date specified in the approval and will continue to be subject for at least two
complete calendar years after the effective date of this agreement and thereafter until this elective coverage is terminated as provided by
the CUIC.
I declare that this application has been examined by me and, to the best of my knowledge and belief, is true and correct and made in
good faith under the provisions of the CUIC, and that I have posted the Notice to Employees Elective Coverage Application for
Unemployment Insurance – State Disability Insurance, DE 1375, in a prominent place on my premises.
This declaration must be signed by one or
Signed
Date
more persons shown under Item 5. If the
application is a partnership all partners must
Print Name
sign the application. If there are more than
three partners, attach a separate sheet
Signed
Date
bearing the signatures and addresses of
such additional partners.
Print Name
(If necessary, attach a separate sheet with
the additional signatures.)
DE 1378 Rev. 34 (8-16) (INTERNET)
Page 3 of 5
CU
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