Form Ui-1 - Application For Unemployment Insurance Employer Reserve Account
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1
2COMMONWEALTH OF KENTUCKY
This form is to determine if an employer is liable for Unemployment Insurance in
Division of Unemployment Insurance
Kentucky. You must submit this report within 15 days.
P. O. Box 948
Frankfort, Kentucky 40602-0948
NO ACTION WILL BE TAKEN AND
(502) 564-2272
THE FORM RETURNED IF NOT
FAX (502) 564-5442
PROPERLY COMPLETED AND
SIGNED.
APPLICATION FOR UNEMPLOYMENT INSURANCE
PART I - IDENTIFICATION AND TYPE OF EMPLOYMENT
EMPLOYER RESERVE ACCOUNT
1.
Name & Mailing Address:
UI-1 (R. 06/91)
(To be completed by all employers)
5.
Check type of employment and complete remainder
of form as indicated.
Acquired all or part of an existing business - Parts II and VI
New Business Employer - Parts II and III
Domestic Employer - Parts II and IV
Agricultural Employer - Parts II and V
New 501(c)(3) Non-Profit Employer - Part I Only*
Governmental Entity - Part I Only*
2.
Telephone #
(
)
Resumed Employment - Part II
Fax #
(
)
Enter Date Employment Resumed:
* Form UI-1S will be sent to you upon return of this form.
3.
Federal Employer ID
4.
If you have previously been assigned an Unemployment Insurance Number, enter it here:
PART II - GENERAL INFORMATION
6.
Describe MAJOR Business Activity IN KENTUCKY (BE SPECIFIC)
(a)
Retail Trade (Product)
(h)
Wholesale Trade (Product)
(b)
Service (Type)
(I)
Manufacturing (Product)
(c)
Construction (Type)
(j)
Domestic
(d)
Agricultural (Type)
(k)
Mining (Product)
(e)
Ag. Service (Type)
(l)
Other (Explain)
(f)
Finance/Insurance/Real Estate (Product)
(g)
Transportation/Communication/Utilities (Type)
7.
Is the establishment primarily engaged in performing services for other units of the company?
YES
NO
If, “YES”, indicate the nature of activity of this establishment:
(a)
Central Administrative Office
(c)
Storage (warehouse)
(b)
Research, development or testing
(d)
Other (specify: power plant, etc.)
8.
Identification of Owner, Partners, (General or Limited), Corporate Officers, etc.
SOCIAL SECURITY NUMBER
FIRST NAME
M.I.
LAST NAME
TITLE
TELEPHONE NO.
RESIDENCE ADDRESS
9.
Name, Mailing Address and Telephone Number of person with payroll records (if different from above):
10.
Type of Organization:
Sole Proprietorship
Partnership
Corporation*
Other
* Corporations Only - List state in which incorporated and give name and address of process agent in Kentucky:
11.
Provide the following information for each establishment or location in Kentucky:
Physical Location of Business in Kentucky (Street, City, Zip Code)
County
No. of Workers
Check here if you wish to file a separate wage and tax report for each location.
12.
Prior to beginning employment in Kentucky, were you subject in the current or preceding year under the unemployment compensation
law of any other state?
YES
NO
If “YES”, what State:
PART III - NEW BUSINESS EMPLOYMENT (Do not include agricultural or domestic employment!) (INCLUDE CORPORATE OFFICERS!)
13.
Date on which you first employed a worker in Kentucky (month, day, year):
14.
Date you first paid wages in Kentucky (month, day, year):
15.
Have you or do you expect to have a quarterly payroll of at least $1,500.00?
YES
NO
If “YES” in what month and year did (or will) this first occur?
Month
Year
16.
Have you or do you expect to employ at least one worker in 20 different calendar weeks during a calendar year?
YES
NO
If “YES” in what month and year did (or will) the 20th week occur?
Month
Year
Signature:
I hereby affirm that I am authorized to sign this report on behalf of the indicated employer, and further affirm that the information provided herein is
complete and accurate to the best of my knowledge. I understand that I may be subject to the full penalty of the law for knowingly making a false
statement (KRS 341.990).
SIGNATURE
TITLE
DATE
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