Form De 1378a - Application For Unemployment Insurance, State Disability Insurance, And Paid Family Leave Elective Coverage - 2016

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APPLICATION FOR UNEMPLOYMENT INSURANCE, STATE DISABILITY INSURANCE, AND PAID FAMILY LEAVE
ELECTIVE COVERAGE UNDER SECTION 708(a) OF THE CALIFORNIA UNEMPLOYMENT INSURANCE CODE (CUIC)
Complete this application only if you meet the requirements as set forth
FOR DEPARTMENT USE ONLY
0B
in the attached Information Concerning Elective Coverage.
DIEC
-
-
APPROVED:
DENIED:
ACCOUNT #
NOTE: For assistance in completing this application, contact the nearest
EFFECTIVE DATE
SUBJECT
Employment Tax Office or call 888-745-3886. Upon completion of the
-
QUARTER
application, return to:
Attention: Analysis Resolution and Correspondence Organization
SEND FORMS
Employment Development Department
DE 2515, DE 3816DI, DE 1378DI
DE 3DI QTR(S)
PO Box 2068
Rancho Cordova, CA 95741-2068
DATE FORMS SENT:
APPROVED BY:
APPROVAL DATE:
PLEASE TYPE OR PRINT ALL INFORMATION CLEARLY.
ON-LINED BY:
ON-LINED DATE:
1.
SOCIAL SECURITY NUMBER*
2.
EMPLOYER ACCOUNT NUMBER
3.
GENDER
4. YEAR OF BIRTH
-
-
-
-
MALE
FEMALE
5. FIRST NAME
MIDDLE INITIAL
LAST NAME
6.
HAVE YOU APPLIED FOR ELECTIVE
COVERAGE BEFORE?
YES
NO
IF YES, ______
______
MO.
YR.
7. MAILING ADDRESS: NUMBER AND STREET OR PO BOX
CITY
ZIP CODE
8. BUSINESS NAME (IF ANY)
BUSINESS PHONE
(
)
9. BUSINESS ADDRESS: NUMBER AND STREET OR PO BOX
CITY
ZIP CODE
10.
EMAIL ADDRESS
11. WEBSITE
12.
DO YOU HAVE ANY EMPLOYEES?
IF YES, AND YOU ARE NOT REGISTERED WITH THE EMPLOYMENT DEVELOPMENT DEPARTMENT (EDD)
AS AN EMPLOYER, PLEASE EXPLAIN:
YES
NO
IF NO, SEE INSTRUCTIONS
13.
TYPE OF ORGANIZATION:
CORPORATION – DO NOT SUBMIT, CORPORATE OFFICERS ARE EMPLOYEES AND COVERED
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 PARTNERS MAY APPLY
LIMITED LIABILITY PARTNERSHIP – ONLY GENERAL PARTNERS MAY APPLY
LIMITED LIABILITY COMPANY – PARTNERSHIP
LIMITED LIABILITY COMPANY – SOLE PROPRIETORSHIP MANAGING MEMBER
14. NAME(S) AND TITLE OF ALL PARTNERS AND MEMBERS (CONTINUE ON ANOTHER PAGE IF NECESSARY)
GENERAL PARTNERS/MEMBERS
SOCIAL SECURITY NUMBER*
LIMITED PARTNERS/MEMBERS
SOCIAL SECURITY NUMBER*
15.
NATURE OF BUSINESS:
CONTRACTING
MANUFACTURING
REPAIRING
RETAIL TRADE
SERVICE
WHOLESALE TRADE
OTHER (DESCRIBE):
16.
YOUR OCCUPATION/TITLE
17. DESCRIBE THE TYPE OF SERVICE, TYPE OF CONTRACTING, OR PRODUCT SOLD.
18.
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
19.
ARE YOU CONDUCTING A SEASONAL TYPE OF BUSINESS?
20. DO YOU EXPECT TO REMAIN IN BUSINESS FOR THE NEXT EIGHT (8) CALENDAR
QUARTERS?
YES
NO
IF YES, AND YOU ANSWER NO IN #23, DO NOT
YES
NO
IF NO, DO NOT SUBMIT, YOU ARE NOT ELIGIBLE FOR
SUBMIT, YOU ARE NOT ELIGIBLE FOR THIS
THIS COVERAGE. SEE INFORMATION SHEET ATTACHED.
COVERAGE. SEE INFORMATION SHEET ATTACHED.
21.
HOW MANY HOURS A DAY, WEEK, MONTH DO YOU PERFORM YOUR
22. DO YOU LIMIT THE NUMBER OF HOURS YOU PERFORM SERVICES?
SERVICES? INCLUDE ADMINISTRATIVE HOURS AND TIME SPENT
SOLICITING CUSTOMERS.
YES
NO
(IF YES, EXPLAIN IN #31)
DAY__________ WEEK_________ MONTH __________ (COMPLETE ALL THREE)
(HOURS)
(HOURS)
(HOURS)
*The disclosure of your Social Security number is mandatory under the Federal Tax Reform Act of 1976.
DE 1378A Rev. 39 (11-16) (INTERNET)
Page 1 of 4
CU

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