Form De 1378a - Application For Unemployment Insurance, State Disability Insurance, And Paid Family Leave Elective Coverage - 2016 Page 2

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23.

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

24.

HOW LONG HAVE YOU HAD EMPLOYEES WORKING FOR YOU?

YEAR(S)

MONTH(S)

IF LESS THAN ONE YEAR, GIVE DATE FIRST EMPLOYEE WAS HIRED ____/____/_________

25.

IF YOU ARE SELF-EMPLOYED AND ALSO AN EMPLOYEE, DO YOU RECEIVE THE MAJOR PART OF YOUR INCOME FROM YOUR SELF-EMPLOYMENT?

YES

IF YES, WHAT PERCENTAGE?

IF NO, EXPLAIN MAJOR SOURCE OF REMUNERATION.

26.

IF YOU WERE SELF-EMPLOYED DURING THE LAST TWO YEARS, WHAT

IF YOU HAVE NEVER FILED A SCHEDULE SE WITH THE IRS, DID YOU HAVE NET PROFIT

WAS YOUR NET PROFIT AS SHOWN ON YOUR IRS SCHEDULE SE, LINE 3?

IN EXCESS OF $4,600 LAST YEAR?

YES

__________

$_____________

__________

$_____________

YEAR

NET PROFIT

YEAR

NET PROFIT

IF YOU HAVE BEEN IN BUSINESS FOR LESS THAN ONE YEAR, DID YOUR AVERAGE NET

PROFIT EXCEED $1,150 PER QUARTER?

YES

IF YOU HAVE BEEN IN BUSINESS LESS THAN ONE QUARTER, DO YOU EXPECT YOUR

AVERAGE NET PROFIT TO EXCEED $1,150 PER QUARTER DURING THE FIRST YEAR IN

BUSINESS?

YES

PLEASE SUBMIT COPIES OF YOUR IRS SCHEDULE SE FOR THE LAST TWO YEARS. IF ONLY IN BUSINESS ONE YEAR, ENTER ZERO FOR THE OTHER YEAR.

IF YOU ANSWERED NO TO ALL THREE QUESTIONS, DO NOT SUBMIT THIS APPLICATION UNTIL YOU EARN THE REQUIRED MINIMUM NET PROFIT IN YOUR TRADE,

BUSINESS, OR OCCUPATION.

27.

WERE YOU CONVICTED OF A MISDEMEANOR UNDER THE CALIFORNIA UNEMPLOYMENT INSURANCE CODE DURING THE LAST EIGHT (8) CALENDAR QUARTERS?

(SEE ATTACHED INFORMATION SHEET)

YES

DO YOU PRESENTLY HAVE AN ILLNESS, FAMILY CARE NEED, OR DISABILITY BONDING NEED WHICH PREVENTS YOU FROM CURRENTLY PERFORMING ALL YOUR

28.

REGULAR AND CUSTOMARY SERVICES IN CONNECTION WITH YOUR TRADE, BUSINESS OR OCCUPATION?

YES

IF YES, WAIT TO SUBMIT UNTIL YOU ARE ABLE TO PERFORM ALL DUTIES.

29.

HAVE YOU BEEN DISABLED OR ON LEAVE TO BOND

IF YES, DID YOU FILE A CLAIM FOR BENEFITS?

WHEN DID YOU RESUME YOUR USUAL DUTIES?

WITH A NEW CHILD OR TO CARE FOR A SERIOUSLY

(DO NOT FILE THIS APPLICATION IF YOU ARE

ILL FAMILY MEMBER DURING THE LAST THREE

CURRENTLY DISABLED.) ______/______/_________

MONTHS?

YES

30.

ON WHAT DATE DO YOU WISH ELECTIVE COVERAGE TO COMMENCE? KEEP IN MIND THAT THE COMMENCEMENT DATE OF AN ELECTIVE COVERAGE

AGREEMENT SHALL NOT BE PRIOR TO THE FIRST DAY OF THE CALENDAR QUARTER IN WHICH THE APPLICATION IS FILED, NOR LATER THAN THE FIRST DAY OF

THE FOLLOWING CALENDAR QUARTER.

FIRST DAY OF CURRENT QUARTER

DAY FIRST EMPLOYEE HIRED

FIRST DAY OF NEXT QUARTER

31.

ADDITIONAL INFORMATION (USE THIS SPACE TO MORE FULLY DISCUSS THE ABOVE QUESTIONS).

NOTE:

DO NOT SEND PAYMENT WITH THIS APPLICATION. IF APPROVED, YOU WILL BE NOTIFIED WHEN PAYMENT IS DUE. IF

YOU ARE ILLEGALLY IN THE UNITED STATES, YOU ARE NOT ELIGIBLE FOR BENEFITS AND ARE LIABLE TO REPAY

ANY BENEFITS PAID TO YOU. IF YOU NEED ADDITIONAL INFORMATION, PLEASE SEE PAGE 1 OF THIS FORM FOR

CONTACT INFORMATION.

I, the undersigned, declare that the statements made on this application are true and correct to my best knowledge and belief. I understand that providing false information will result in

denial or termination of coverage. I hereby elect and make application to have my services considered as employment subject to the California Unemployment Insurance Code (CUIC)

for Unemployment Insurance, State Disability Insurance, and Paid Family Leave. I hereby authorize the verification of any information provided by me on this application. I understand

that this election must remain in effect for two complete calendar years unless I no longer meet all of the eligibility requirements of Section 704 of the

CUIC

or I meet the conditions for

termination of coverage under Section 704.1 of the CUIC.

SIGNATURE OF APPLICANT

DATE

RESIDENCE ADDRESS (NUMBER AND STREET OR PO BOX, STREET, CITY, AND ZIP CODE)

RESIDENCE PHONE

(

)

APPLICATION MUST BE SIGNED TO BE VALID

DE 1378A Rev. 39 (11-16) (INTERNET)

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