Form De 1378j - Application For Elective Coverage Of Disability Insurance (Excluded Family Employment) - California Edd
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1
2FOR DEPARTMENT USE ONLY
ACCOUNT NUMBER
STATISTICAL CODE
EFFECTIVE DATE
DATE EMPLOYER NOTIFIED
Analysis Resolution and Correspondence Organization
PO Box 2068
APPROVED BY
DATE APPROVED
Rancho Cordova, CA 95741-2068
888-745-3886
APPLICATION FOR ELECTIVE COVERAGE OF
SEND
NUMBER OF EMPLOYEES
DISABILITY INSURANCE (Excluded Family Employment)
Reference:
California Unemployment Insurance Code
Section 702.5 of the
PLEASE PRINT OR TYPE
IMPORTANT
This form is not an application for an account number under the compulsory provisions of the California Unemployment Insurance Code (CUIC). Do not
complete this form unless both the owner of the entity described herein and its family employees, excluded under Section 631 of the CUIC, wish to have
the employees’ services voluntarily covered for State Disability Insurance* under the provisions of Section 702.5 of the CUIC.
1. Employer Name
Social Security Number
2. Business Name
3. Business Address
Number and Street
City and State
ZIP Code
4. Mailing Address
Number and Street
City and State
ZIP Code
5. Your Employer Payroll Tax Account Number(s), if any
6. Nature of Business (Check One)
Retail Trade
Service
Manufacturing
Agricultural
Wholesale Trade
Repairing
Contracting
Other
Describe product or service:
Manufacturers: List principal products in order of importance:
7. If your business is seasonal, in what months do you operate?
8. Do you expect to remain in business for the next eight (8) calendar quarters?
9. What types of services are performed by excluded family employees?
10. Do you report (or are you required to report) to Social Security for excluded family employees?
Yes
No (Please explain)
11. How many employees will be covered by this agreement?
12. What is the number of locations at which your business is conducted in California?
List locations covered by this application.
13. Deductions should not be made from your employees’ wages for the purpose of paying contributions until your application has
been approved. If deductions have already been made, indicate beginning date.
Deducted From (Date)
Amount
Were such deductions made on all employees covered by this application?
$
14. On what date do you desire elective coverage to begin?
First Day of Current Quarter
First Day of Next Quarter
*Includes Paid Family Leave (PFL).
CONTINUED ON REVERSE
DE 1378J Rev. 10 (8-16) (INTERNET)
Page 1 of 2
CU
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