Form De 1378j - Application For Elective Coverage Of Disability Insurance (Excluded Family Employment) - California Edd Page 2

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List the name(s), age(s), relationship, and Social Security number(s) of

Is this person currently

Has this person filed a

How long has the

Will you pay wages

those electing the coverage. The signature of each employee electing the

performing normal and

claim for benefits within

person been

to this person?

coverage is required for this election. (If more space is needed, please

customary services in

the last three months?

working in your

If so, how often?

attach a continuation sheet with the needed information and signatures.)

connection with the

business?

(Weekly, monthly,

operation of your business?

etc.)

(If no, explain below.)

Name

Age

Relationship

Yes

Month(s)

How often?

Signature

Social Security Number

Name

Age

Relationship

Yes

Month(s)

Yes

How often?

Signature

Social Security Number

Name

Age

Relationship

Yes

Month(s)

Yes

How often?

Signature

Social Security Number

Name

Age

Relationship

Yes

Month(s)

How often?

Signature

Social Security Number

Explanation

NOTE: If your application is approved, the elective coverage agreement will be subject to all of the requirements and conditions of Sections 631, 702.5, 704, and 707 of the CUIC.

Eligibility for State Disability Insurance* benefits under the CUIC does not begin with the commencement date of coverage. Generally, a minimum of seven (7) months must elapse from the

commencement date of coverage before a valid claim may be filed based solely on wages reportable under your election.

CERTIFICATION:

I, the undersigned, certify that the statements made in this application are true and correct to my best knowledge and belief. I hereby elect and make application to have the excluded family services

considered as employment subject to the CUIC for State Disability Insurance only. The elective agreement is to be in effect for at least two complete calendar years or until termination of employment

in my business. The elective agreement may be terminated by filing a request for termination by January 31 of any year following two complete years of elective coverage.

Employer Signature

Date

Residence Address Number and Street

Business Phone

Residence Phone

City and State

ZIP Code

NOTE: The employees who are covered by election under Section 702.5 of the CUIC are also subject to the California Personal Income Tax (PIT) withholding law. Agricultural employees are not

subject to the California PIT withholding law unless both the employer and employee agree to have the state PIT withheld.

Wages and Contributions, Section 702.5:

Contributions to be paid for “Family Employment” elective coverage are to be based upon actual wages paid to covered family members for services performed up to a maximum wage limitation for the

year for each family member.

There is no provision in this section to permit the contributions to be based on other than actual wages paid.

The amount of any disability benefits paid will also be determined on the basis of wages paid.

Social Security Number Disclosure:

The disclosure of your Social Security number is mandatory under the Federal Tax Reform Act of 1976. The number will be used for identification purposes and will be available only to authorized

personnel within the Employment Development Department (EDD) and other government agencies as permitted in Sections 322 and 1095 of the CUIC.

The EDD is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Requests for services, aids, and/or alternate formats need to be

made by calling 888-745-3886 (voice) or TTY 800-547-9565.

*Includes PFL

DE 1378J Rev. 10 (8-16) (INTERNET)

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