Form De 1378di - Application For Disability Insurance Elective Coverage (Diec) - California Edd - 2016
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1
2Application For Disability Insurance Elective Coverage (DIEC)
For Department Use Only
Complete this application only if you meet the requirements as set
forth in the attached Information Concerning Elective Coverage.
DIEC
DIEC
—
—
Approved:
708(b)
708.5
Account #
NOTE: For assistance in completing this application, contact
Effective Date:
Subject
the nearest Employment Tax Office or call 888-745-3886.
—
Quarter
Upon completion of this application, return to:
Attention: Analysis Resolution and Correspondence Organization
Send Forms
Employment Development Department
DE 2515, DE 3816DI
DE 3DI Qtr(s) __________________________
PO Box 2068
Date Forms Sent:
Approved By:
Approval Date:
Rancho Cordova, CA 95741-2068
Rev/Reg By:
Rev/Reg Date:
Please type or print all information clearly.
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
Corporation - Do not submit, corporate officers are employees and covered under the State Disability Insurance Program.
13. Type of Organization:
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
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/Managing 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?
Yes
No
Do you possess such a valid and active
Provide License/Permit Number
If yes, indicate type of license or permit required:
license?
Yes
No
20. Do you expect to remain in business for the next eight (8) calendar quarters?
19. Are you conducting a seasonal type of business?
YES
NO
If yes, do not submit. You are not eligible for this coverage. See information sheet attached.
Yes
No
If no, do not submit. You are not eligible for this coverage.
See information sheet attached.
21. Do you perform services in your trade, business, or occupation continuously throughout the year?
If no, explain.
(include time spent doing office work, soliciting customers, and maintaining machinery and
equipment.)
Yes
No
*The disclosure of your Social Security number is mandatory under the Federal Tax Reform Act of 1976.
DE 1378DI Rev. 44 (11-16) (INTERNET)
Page 1 of 4
CU
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