Form De1378a - Application For Unemployment And Disability Insurance Elective Coverage Under Section 708(A) Of The Unemployment Insurance Code - 2003
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2APPLICATION FOR UNEMPLOYMENT AND DISABILITY INSURANCE ELECTIVE COVERAGE
UNDER SECTION 708(a) OF THE UNEMPLOYMENT INSURANCE CODE
Complete this application only if you meet the requirements as set forth
FOR DEPARTMENT USE ONLY
in the attached Information Concerning Elective Coverage.
DIEC
-
-
APPROVED:
708(a)
ACCOUNT #
*The disclosure of your Social Security Account Number is mandatory under
the Federal Tax Reform Act of 1976.
EFFECTIVE DATE
SUBJECT
-
QUARTER
NOTE: If you require any assistance in the completion of this application,
contact the nearest Employment Tax Customer Service Office of this
SEND FORMS
Department, or call (916) 464-2500. Upon completion of the application, return
DE 2515, DE 3816A, DE 5137,
DE 3DI QTR(S)
to: Employment Development Department, Audit Section, MIC 94,
10969 Trade Center Drive, Suite 203, Rancho Cordova, CA 95670.
DATE FORMS SENT
CLASSIFIED BY
DATE
PLEASE TYPE OR PRINT ALL INFORMATION CLEARLY
1.
SOCIAL SECURITY NUMBER*
2.
CALIF. EMPLOYER ACCOUNT NUMBER
3.
SEX
YEAR OF BIRTH
-
-
-
-
MALE
FEMALE
4.
YOUR NAME
FIRST
MIDDLE INITIAL
LAST
5.
HAVE YOU APPLIED FOR ELECTIVE
COVERAGE BEFORE?
YES
NO
IF YES, ______
______
MO.
YR.
6.
MAILING ADDRESS: NUMBER OR P.O. BOX, STREET
CITY
ZIP CODE
7.
BUSINESS NAME (IF ANY)
BUSINESS TELEPHONE
(
)
8.
BUSINESS ADDRESS: NUMBER OR P.O. BOX, STREET
CITY
ZIP CODE
9.
DO YOU HAVE ANY EMPLOYEES?
IF YES, AND YOU ARE NOT REGISTERED WITH THIS DEPARTMENT AS AN EMPLOYER, PLEASE EXPLAIN:
YES
NO
IF NO, SEE INSTRUCTIONS
10. TYPE OF ORGANIZATION:
CORPORATION – DO NOT SUBMIT, CORPORATE OFFICERS ARE EMPLOYEES NOT SELF-EMPLOYED.
GENERAL PARTNERSHIP (INCLUDES HUSBAND AND WIFE CO-OWNERS WHO ARE BOTH ACTIVE IN THE OPERATION AND
MANAGEMENT OF THE BUSINESS.)
INDIVIDUAL
LIMITED PARTNERSHIP – ONLY GENERAL PARTNER MAY APPLY
11. NAME(S) AND TITLE OF ALL PARTNERS (CONTINUE ON ANOTHER PAGE IS NECESSARY)
GENERAL PARTNERS
Social Security Number*
LIMITED PARTNERS
Social Security Number*
12. NATURE OF BUSINESS:
CONTRACTING
MANUFACTURING
REPAIRING
RETAIL TRADE
SERVICE
WHOLESALE TRADE
OTHER (DESCRIBE):
13. YOUR OCCUPATION/TITLE
14.
DESCRIBE THE TYPE OF SERVICE, TYPE OF CONTRACTING, OR PRODUCT
SOLD.
15. IS A LICENSE OR PERMIT REQUIRED IN YOUR TRADE, BUSINESS OR OCCUPATION?
DO YOU POSSESS SUCH A
PROVIDE LICENSE/PERMIT NUMBER
YES
NO
IF YES, INDICATE TYPE OF LICENSE OR PERMIT REQUIRED:
VALID AND ACTIVE LICENSE?
YES
NO
16. ARE YOU CONDUCTING A SEASONAL TYPE OF BUSINESS?
17.
DO YOU EXPECT TO REMAIN IN BUSINESS FOR THE NEXT EIGHT (8)
CALENDAR QUARTERS?
YES
NO
IF YES, AND YOU ANSWER NO IN #20, DO NOT
SUBMIT, YOU ARE NOT ELIGIBLE FOR THIS
YES
NO
IF NO, DO NOT SUBMIT, YOU ARE NOT ELIGIBLE FOR THIS
THIS COVERAGE. SEE INFORMATION SHEET ATTACHED.
COVERAGE. SEE INFORMATION SHEET ATTACHED.
18. HOW MANY HOURS A DAY, WEEK, MONTH DO YOU PERFORM YOUR
19.
DO YOU LIMIT THE NUMBER OF HOURS YOU PERFORM SERVICES?
SERVICES? INCLUDE ADMINISTRATIVE HOURS AND TIME SPENT
SOLICITING CUSTOMERS.
DAY__________ WEEK_________ MONTH __________ (COMPLETE ALL THREE)
YES
NO
(IF YES, EXPLAIN IN #29)
(HOURS)
(HOURS)
(HOURS)
20. DO YOU PERFORM SERVICES IN YOUR TRADE, BUSINESS, OR
IF NO, EXPLAIN.
OCCUPATION CONTINUOUSLY THROUGHOUT THE YEAR? (INCLUDE TIME
SPENT DOING OFFICE WORK, SOLICITING CUSTOMERS AND MAINTAINING
MACHINERY AND EQUIPMENT.)
YES
NO
DE 1378A Rev. 34 (5-03) (INTERNET)
Page 1 of 4
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